Football in Times of COVID-19: A Recapitulation of Preventive Measures and Infection Control Policies Aiming at a Safe Game Environment

in International Journal of Sports Physiology and Performance

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Karim ChamariOrthopedic and Sports Medicine Hospital, FIFA Medical Center of Excellence, Aspetar, Doha, Qatar

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Ismail DergaaPrimary Health Care Corporation (PHCC), Doha, Qatar

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Inigo MujikaDepartment of Physiology, Faculty of Medicine and Nursing, University of the Basque Country, Leioa, Basque Country, Spain

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Yorck Olaf SchumacherOrthopedic and Sports Medicine Hospital, FIFA Medical Center of Excellence, Aspetar, Doha, Qatar

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Montassar TabbenOrthopedic and Sports Medicine Hospital, FIFA Medical Center of Excellence, Aspetar, Doha, Qatar

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Helmi Ben SaadResearch Laboratory (LR12SP09, Heart failure), Farhat HACHED Hospital of Sousse, Faculty of Medicine of Sousse, University of Sousse, Sousse, Tunisia

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Coronavirus disease 2019 (COVID-19) resulted in sporting event suspensions and cancellations, affecting competition calendars worldwide during 2020 and 2021. This challenged high-performance athletes’ capacity to complete physical, technical, or tactical training during restricted movement measures (lockdown). With the Football World Cup organized in the last quarter of 2022, the past period of training and match disturbances challenged footballers concerning their performance and potential higher risk of injury at official matches’ resumption. There has been considerable debate about the management of resuming professional football (soccer) during the COVID-19 pandemic. Governing bodies worldwide implemented measures to ensure a safe resumption of football. These precautionary measures aimed to protect the health of players, their support staff, and officials around the pitch and ensure the enjoyment of the event by spectators in the football stadiums. We have therefore narratively reviewed scientific papers about how football has resumed on the pitch and in the stands with special focus on the COVID-19 infection control strategies allowing footballers to perform again and supporters to enjoy the game after the 2020 global stop to sport.

The coronavirus disease 2019 (COVID-19) pandemic hampered many people’s capacity to engage in physical activity and benefit from sporting involvement.1,2 Event suspensions and cancellations have wrecked both recreational and elite competition calendars worldwide, mainly in 2020 and 2021. Athletes’ training was troubled for a variety of reasons,36 and closures of specialized training facilities were common, in addition to limited access to multidisciplinary coaching support and medical care.3,4 Social distancing precluded physical engagement for team-based technical and tactical training, challenging both team and collision sports.7,8 This clearly challenged high-performance athletes’ capacity to complete physical, technical, or tactical training, potentially threatening their performance, as the latter strongly depends on the availability of players to train and compete.912 Creative, often home-based training solutions were used by athletes in an attempt to maintain physical and technical capabilities, and decrease injury risk upon return.3,10 The pandemic-related lockdown, however, induced substantial declines in variables such as maximal oxygen consumption and muscular mass/strength.13,14 The stress/anxiety experienced in seclusion also negatively impacted athletes’ sleep and/or mental health.1518 Therefore, stopping training and competition and staying confined made players impatient to resume their normal training and competition routines.

There has been considerable debate about the management of resuming professional sports, particularly football (soccer), during the COVID-19 pandemic.1,3 Under the strong will of players and clubs,4 governing bodies worldwide implemented measures to ensure a safe sporting resumption.1,4 These precautionary measures were aimed at protecting the health of players and officials, as well as the enjoyment of the event by spectators.4,7,9,13 Various hygiene measures were implemented in football to reduce COVID-19 transmission,4,7,9,13 but their effectiveness depended on adherence by all involved parties.4 When a footballer became infected, the question of whether it occurred in connection with training/matches or in a different environment arose.17 Analysis of transmission-relevant contacts can be used as a reasonable approach to assess the risk of infection.17 The same would be applicable for fans, as for any infected spectator, the question whether increased risk is related to large crowds remained.17

The football events’ resumption was based on specific conditions such as COVID-19 polymerase chain reaction (PCR) tests, continuous education, daily screening, and the gradual lifting of restrictions for spectators. Thus, our purpose was to narratively review scientific papers about how football has resumed on the pitch and in the stands. Special focus was put on the COVID-19 pandemic infection control strategies used aiming at allowing footballers to perform again after the 2020 global stop to sport.

Infection Control for Footballers and Their Supporting Staff

Supplementary Table S1 (available online) exposes the conclusions of the 7 papers addressing the issue of how football has resumed on the pitch and in the stands, during the COVID-19 pandemic.1723

A few studies examined specific contact patterns and the potential risk of respiratory disease transmission on the football field.19,20,24 According to a tracking system, the average exposure time per pair of individuals in a professional football game was 32 seconds.24 In a video-based analysis of 3 matches involving 18 potentially infectious COVID-19-positive football players, contact with the mucosa of the mouth, nose, and eyes (ie, a potential source of virus transmission) was less frequent in infected players than in everyday situations.19 A video analysis of 50 football games revealed that common player behaviors that increase aerosol and droplet production (eg, talking, shouting, and spitting) were extremely rare.20

In a study assessing the risk of COVID-19 transmission from on-field player contacts in amateur, youth, and professional football, Schreiber et al18 reported that 104 cases (38 training sessions and 66 matches) with 165 potentially infectious players were detected out of 1247 identified football matches and training sessions (1071 amateur and youth levels; 176 professional level). Professional-level PCR testing (44 cases) revealed no evidence of transmission.18 At the amateur and youth levels, a combination of partial PCR testing (31 of 60 cases) and symptom monitoring within 14 days of exposure (46 of 60 cases) identified 2 of 60 matches where follow-up infections were attributed to nonfootball activities.18 This is consistent with a video analysis of 21 matches, revealing that frontal contacts were 1 per player-hour (88%, 30 of 34 players), with each lasting no more than 3 seconds.18 According to the authors, the risk of COVID-19 transmission on the football field is relatively low, and the infections in football players are most likely not caused by activities on the field.18

Another study reported that 1 professional player had suspicious symptoms after the COVID-19 shutdown in the Bundesliga.17 PCR testing prior to training showed that 8 players and 4 officials tested positive during the first rounds, and 2 more players tested positive during the third round of games.17 For the rest of the season, there were no more COVID-19-positive results.17 Six hundred and ninety-nine players and officials gave 2 serum samples for antibody testing.17 Nine players converted from negative, or borderline, to positive (with no symptoms); 2 players who initially tested positive then tested negative at the end of the season.17 Throughout the season, 22 players remained seropositive. In the neutralization test, none of the seroconversions were confirmed. The authors therefore claimed that professional football training and matches could be held safely during the COVID-19 pandemic if strict hygiene precautions are taken, including regular PCR testing.17 Similarly, the seroprevalence of 2164 samples from 1184 players and staff was similar in May 2020 (23/1157, 1.99%), and June 2020 (21/1007, 2.09%).21 However, during the study period, all participants tested negative for PCR, and there were no significant regional differences in seroprevalence.21 When seroprevalence was compared with the cumulative incidence of infections from the German notification system (subgroup matching to cohort; men aged 20–69 y), immunoglobulin G was found 8 to 10 times more frequently, indicating a high rate of undetected infection in footballers.21 The authors concluded that in Germany, seroprevalence with high-quality diagnostics appeared to be around 2%, and that the number of infections that went unnoticed is thought to be 8 to 10 times higher than the number of infections that people are informed about.21

In a related study conducted by Schumacher et al,22 the researchers investigated the infective and immune status of 1377 professional football players, team staff, and league officials in professional football in Qatar in 2020. This analysis was performed during a shortened football season that resumed at the height of the COVID-19 pandemic in a country with high infection rates. The study also reported the main clinical symptoms associated with COVID-19 infection in professional players.22 The authors stated that 85 participants tested positive during the research period,22 an infection rate comparable with that of the general population.22 Moreover, half of the infected footballers were asymptomatic, and the rest had only mild symptoms, none requiring hospitalization.22 Symptom severity was associated with lower cycle threshold (ct) values from PCR testing.22 The most common sources of infection were social connections and family, and no infection could be linked to training or matches.22 During the study period, 15 of the 36 infected players had positive serology.22 The authors concluded that when preventive measures are in place, outdoor football has a low risk of COVID-19 infection and severe disease, even when players have close contact.22 In that regard, the same group investigated whether the surface transmission in football facilities could be at the origin of COVID-19 contamination.23 For that purpose, surfaces in frequently cleaned training facilities, locker rooms, and medical and administrative spaces were swabbed for COVID-19 in random locations (eg, high-touch areas, ventilation systems, toilets, cleaning equipment, freezers, and pantries) in 6 clubs from Qatar professional league. The authors reported that none of the 103 swabs had a strong viral presence with a ct value <30 (ie, suggestive of potential surface transmission).23 Four samples had ct values ranging from 30 to 35 (ie, indicating a modest quantity of virus), while 16 swabs had ct values ranging from 35 to 40 (ie, inactive virus remnants).23 The remaining 83 samples (ie, ct > 40) were negative.23 The majority of samples containing viral or viral remnants were from high-touch locations.23 Despite the fact that some footballers in the investigated clubs had been infected, there was no evident sign of surface transmission in football club facilities when standard cleaning procedures were used in addition to close monitoring of the players.22

As a limitation, the studies assessing infection control contain bias that may skew the results,1723 as none of them considered the different strains when designing their various protocols. Assessing the infection rate during a match, training, or in the changing room would be very different among severe acute respiratory syndrome coronavirus 2 strains Alpha, Delta, or Omicron; each of these variants (and potentially subvariant) has a different R0 (R0 value represents the average number of people infected by 1 infectious individual and shows how quickly the virus can spread).2528 Most of these studies examined the infection rates in periods with predominant Alpha and Beta strains (between early 2020 and mid-2021), which may explain the low infection risk during matches and training (Supplementary Table S1 [available online]). However, throughout the particular instance of strain Omicron and the African Confederation Cup, which was held in Cameroon from January 9, 2022 to February 6, 2022, nonscientific/media reports indicated high potential infection risk during matches and/or training.29 This scenario may be a potential threat for the safe organization of football tournaments in the presence of such a virus strain.

Infection Control for Football Supporters

The COVID-19 pandemic was considered a potential threat to professional sporting events with football stadiums typically seating more than 40,000 people for big events.7,9 Qatar was the first country to host a large number of spectators after COVID-19 was declared a pandemic7,9 during the Amir Cup Final in December 2020, when no COVID-19 vaccines were available yet.7 A total of ∼20,000 spectators attended (50% of the stadium capacity) with a negative antigen test performed within the 72 hours preceding the game. Upon stadium entry social distancing, temperature screening, and mask wearing were required.7 The antigen test and monitoring results were recorded using a geolocating cell phone app and an online booking system. While this was an expensive exercise for both the organizers and the spectators, as far as the researchers were aware, the Amir Cup Final was a success in terms of managing the risk of COVID-19.7 This event was the first to demonstrate that when strict infection control policies are implemented, it is possible to organize a major football match held outdoors in times of COVID-19 pandemic (Alpha variant). Later on, spectators were permitted to attend the Euro 2020 UEFA competition (ie, held in 11 different European countries from June 11, 2021 to July 11, 2021).30,31 For this competition, the spectators were required to mitigate the COVID-19 risk with a prematch negative COVID-19 test.9 COVID-19 vaccines were available in the run-up to the Euro 2020 UEFA competition, adding another risk-mitigation layer to reduce the spread of the COVID-19 virus.30,31 In this context, and in response to the success of the Tokyo Olympic Games in terms of organization and infection control (with limited spectators in the stands), many countries around the world have begun to loosen restrictions on large crowds in football stadiums.9,13 Likewise, many leagues around the world have begun to host football matches with moderate infection control policies and 100% fan capacity attendance.9,13

A short time after the resumption of different football leagues worldwide (ie, in November 2021), the World Health Organization named Omicron, a new variant coronavirus (variant B.1.1.529) of COVID-19.32 At that time, little was known regarding this strain and, accordingly, many scientists were worried about the world global health, especially as this variant had the potential to increase transmissibility, confer resistance to therapeutics, or partially escape infection- or vaccine-induced immunity.30 In this context, Dergaa et al9,13 hypothesized that COVID-19 may undergo further mutations, potentially mutating into severe variant (unlikely), which would be a huge burden for the upcoming FIFA World Cup 2022, or hopefully evolving into less severe variants, meaning the FIFA World Cup 2022 may be held in a more secure environment.9,13 In that regard, the number of visitors to Qatar during the FIFA World Cup 2022 (November and December 2022) is expected to exceed ∼60% of the country’s current population (∼2.2 million people).9,13 Herd immunity appears to have reached its global reach by mid-2022. Concerns about holding a safe FIFA World Cup 2022 seem to be significantly reduced. Fortunately, COVID-19-related deaths are becoming more similar to deaths resulting from flu, and this may be the tipping point for COVID-19 from pandemic to endemic status.33 It is worth noting that infection rates began to rise again in early April 2022. For instance, on April 3, 2022, China reported 13,146 new cases of COVID-19 over the preceding 24 hours, being the highest single-day total of new cases since the peak of the 2020 outbreak, triggering China to declare a full lockdown in the country.34 This shows that COVID-19 was not approaching its end yet everywhere, despite the general encouraging trend described around the world, with football returning to quasi-normalcy. As of June 13, 2022, if no new COVID-19 strains emerge, and if the favorable situation persists, future football events will hopefully be held in the same manner as before COVID-19.

To conclude, it appears in late 2022 that the strict infection control measures that were successfully used at the early times of the COVID-19 pandemic are no longer necessary in football stadiums. However; governments should continue to support vaccine campaigns until COVID-19 is declared endemic, in addition to encouraging individuals to take personal precautions that are probably the most cost-effective and reliable way to stay airborne virus/COVID-19 free and enjoy safe, and cheerful football again.

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Supplementary Materials

  • Collapse
  • Expand
  • 1.

    Corsini A, Bisciotti GN, Eirale C, Volpi P. Football cannot restart soon during the COVID-19 emergency! A critical perspective from the Italian experience and a call for action. Br J Sports Med. 2020;54(20):11861187. doi:10.1136/bjsports-2020-102306

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 2.

    Trabelsi K, Ammar A, Masmoudi L, et al. Globally altered sleep patterns and physical activity levels by confinement in 5056 individuals: ECLB COVID-19 international online survey. Biol Sport. 2021;38(4):495506. doi:10.5114/biolsport.2021.101605

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 3.

    Duarte Muñoz M, Meyer T. Infectious diseases and football—lessons not only from COVID-19. Sci Med Footb. 2020;4(2):8586. doi:10.1080/24733938.2020.1749422

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 4.

    Dergaa I, Abdelrahman H, Varma A, et al. COVID-19 vaccination, herd immunity and the transition toward normalcy: challenges with the upcoming sports events. Ann Appl Sport Sci. 2021;9(3):10. doi:10.52547/aassjournal.1032

    • Search Google Scholar
    • Export Citation
  • 5.

    Washif JA, Mohd Kassim SFA, Lew PCF, Chong CSM, James C. Athlete’s perceptions of a “quarantine” training camp during the COVID-19 lockdown. Front Sports Act Living. 2020;2:622858. doi:10.3389/fspor.2020.622858

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 6.

    Bok D, Chamari K, Foster C. The pitch invader—COVID-19 canceled the game: what can science do for us, and what can the pandemic do for science? Int J Sports Physiol Perform. 2020;15(7):917919.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 7.

    Dergaa I, Varma A, Tabben M, et al. Organising football matches with spectators during the COVID-19 pandemic: what can we learn from the Amir Cup Football Final of Qatar 2020? A call for action. Biol Sport. 2021;38(4):677681. doi:10.5114/biolsport.2021.103568

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 8.

    Stokes KA, Jones B, Bennett M, et al. Returning to play after prolonged training restrictions in professional collision sports. Int J Sports Med. 2020;41(13):895911. doi:10.1055/a-1180-3692

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 9.

    Dergaa I, Musa S, Romdhani M, et al. FIFA World Cup 2022: what can we learn from the inspiring Tokyo 2020 Olympic Games held in COVID-19 times? Biol Sport. 2022;39(4):10731080.

    • Search Google Scholar
    • Export Citation
  • 10.

    Washif JA, Farooq A, Krug I, et al. Training during the COVID-19 lockdown: knowledge, beliefs, and practices of 12,526 athletes from 142 countries and six continents. Sports Med. 2022;52(4):933948. doi:10.1007/s40279-021-01573-z

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 11.

    Pillay L, Janse van Rensburg DCC, Jansen van Rensburg A, et al. Nowhere to hide: the significant impact of coronavirus disease 2019 (COVID-19) measures on elite and semi-elite South African athletes. J Sci Med Sport. 2020;23(7):670679. doi:10.1016/j.jsams.2020.05.016

    • Crossref
    • Search Google Scholar
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