Design a guideline

The success of COVID-19 prevention during football competitions must involve a scientifically based risk mitigation plan that can evolve as new evidence and interventions emerge. This plan must be accepted by all stakeholders, including stadium management, National Federations, and executive committees of leagues and individual teams. A well-designed guideline on COVID-19 risk mitigation should be practical, concise and consider the following8:

• Involvement of the occupational health and safety guidelines of each country to legally align with the host country’s regulations and reflect or exceed the requirements for the general public.

• A specialised team to coordinate the development of protocols in each country. Ideally, this team should comprise medical doctors, legal practitioners, sport administrators, and safety and security professionals with experience in sport. Players and coaches must be educated on the developed protocols and compliance to these protocols is for their own safety, health, and well and the safe continuity of the industry.

• Implementation of the risk mitigation plan must be done by each country’s National Federation or administrative institute. New COVID-19-specific protocols must be adopted into the rules and functional framework to ensure compliance. Non-compliance must be handled by the league or sport governing body, and the consequences for violations clarified and enforced.

• An estimate of the size and density of the crowd should be estimated, ingress and egress within the stadium capacity and infrastructure to define low/medium/high-risk events.

Selection of stadium

Selection of the stadia where matches take place is important, especially regarding capacity and facilities. The following aspects must be considered:

• Surveillance of the region/country as to whether there are COVID-19 incidence surges (‘waves’) or not.

• Positive uptake of vaccinations among local citizens to reduce new COVID-19 infection variants and waves.

• Staggered ingress of spectators to avoid congregation. Those with COVID-19 symptoms should not be allowed entry and referred on for COVID-19 testing.

• Accessible facilities for COVID-19 testing and case management should be located nearby (on-site for suspicious cases). Health facilities should be clearly identified and briefed on their specific responsibilities of medical care.

• Appropriate safety and security around the match precinct to respond to spectators ignoring COVID-19 protocols.

• Hand washing stations or hand sanitiser (preferably containing 70% alcohol) should be provided at the entrance of the stadium and available throughout the complex.

• Cleaning staff attending to ablutions should be trained to don and doff gloves and other personal protective equipment at regular intervals. Personal protective equipment should be available to all cleaning staff.

• Disinfection should occur in public areas and team locker rooms before and after matches.

• Social distanced seating should be implemented with at least 1.5 m between persons (two empty seat distance unless they are of the same household) and not exceeding 50% stadium capacity.

Mass education

This should be reinforced by placing posters in various areas of the stadium that highlight proper mask wearing over the mouth and nose, appropriate social distancing, and hand and respiratory hygiene.

Vaccination

Even though COVID-19 vaccination is still voluntary in most countries, all adult athletes as well as the staff members should be vaccinated against COVID-19. This will reduce the risk of contracting COVID-19 in the team setting and spreading it. Some airlines and countries require proof of full vaccination and/or COVID-19 testing prior to travel to allow entry and to avoid quarantine. Older adults or those with underlying health conditions at greater risk of experiencing a severe COVID-19 illness should be especially targeted—in the team setting this may include coaches and other support staff (ie, kit people, analysts, drivers). Permitting attendance by only vaccinated spectators is strongly advised. Recently, the South African government launched a ‘Return to Play’ vaccination campaign aimed to further encourage the public to go for vaccinations against COVID-19.9 In doing this, they are planning to invite, in conjunction with the South African Football Association, a certain number of ONLY vaccinated spectators to stadia for international competitions. This will be used as a pilot project of returning fans to stadia.10 The UEFA had conducted a successful competition series for the Champions League between June and July 2021. There were specific protocols and requirements in place for attendees.11

Considerations on prevention measures outside the stadia for teams

Risk mitigating measures should extend to higher risk areas outside of the stadia such as hotels and modes of transport. These measures should consider:

• One athlete per room.

• Provision of hand sanitiser.

• Use of face masks when in common spaces.

• Regular COVID-19 PCR testing (1 week and 72 hours prior to accessing the participation bubble, then on arrival, every 48 hours until the competition begins). Rapid antigen testing could be considered an alternative in vaccinated players and staff members. However, it is important to note that antigen testing (point-of-care testing) is not without caveats. Research suggests that optimal quality kits, coupled with appropriate testing process, interpretation, timing and frequency, yield best outcomes when using these tests.12

• A contact tracing system. This may involve epidemiologists, healthcare surveillance teams and match organisers when there is a positive primary case and inform secondary exposures accordingly. There is a challenge in Africa from all these aspects as the appropriate teams and expertise are not easily available. Hence, the contact tracing system may involve a combination of the above with cellular phone industries in order to alert as to whether a match attendee in the past 10–14 days has attended a match and surveillance and response implemented to monitor for a mass super spreader event.13

Recommendations for spectators

Many of the measures outlined for athletes also apply to spectators (table 1).

• Measures like proper face mask use (covering nose and mouth), social and physical distancing, respiratory hygiene and hand sanitising2 must be obligatory.

• Spectators should be fully vaccinated and/or present a recent (within 72 hours) negative COVID-19 PCR/antigen test before attending matches.