A scoping review of the risk factors and strategies followed for the prevention of COVID-19 and other infectious diseases during sports mass gatherings: Recommendations for future FIFA World Cups

Abstract

Objective:

Sports mass gatherings of people pose particular concerns and place an additional burden on the host countries and the countries of origin of the travelers. It is imperative to identify how countries dealt with various communicable diseases in the context of previous world cups and identify possible advice for protection from outbreaks.

Methods:

A scoping review was employed in this study and a PRISMA extension for scoping reviews was employed to guide the reporting of this study. A systematic search was performed using PubMed, Embase, Web of Science, SCOPUS, SportDiscus, and Google scholar. The search strategy included two main strings viz “communicable disease” AND “sport” AND “setting” as keywords for each string. A total of 34 studies were included in this review.

Results:

Information on risk factors for infectious diseases during FIFA, and recommendations for disease prevention in various stages of the event: pre-event, during, and post-event were charted. These strategies can be achieved with the empowerment of the public by enhancing their social responsibility and the coordination between the healthcare system, the ministry of public health, and other stakeholders.

Conclusion:

The findings will support planning for protection strategies to prevent any outbreak while having the FIFA World Cup or any other sports gatherings. A model was constructed to present the findings and recommendations from this review.

1. Introduction

Mass gatherings of people pose particular concerns and place an additional burden on the host countries and the countries of origin of the travelers (1). These mass gatherings could range from global sporting events to global religious occurrences (2–5). A number of health concerns can accompany mass gatherings, including increased human crowding and the spread of pathogens, which can raise the chance of infectious disease spread among attendees, specifically respiratory disease infections, causing pandemics (6, 7).

The World Cup is one of the world's biggest events bringing people and countries together in celebration and competition. The World Cup was hosted previously by several countries where different strategies to reduce the risk and the impact of acquiring communicable diseases during a mass gathering were implemented. Strategies have focused on pre-travel consultation (8, 9), the provision of standard operating procedures for epidemic response (10), and enhanced international multi-disciplinary surveillance to monitor and assess the risk of any infectious disease threats and promptly detect incidents (11–16). Medical facilities were established at the airport for the isolation of patients and extensive staff training was conducted in the use of infection control practices (14). Additionally, close Devi Priya rapid detection of infectious diseases (14).

1.1. FIFA World Cup 2022

Qatar served as the first Middle Eastern host of the FIFA World Cup in 2022 (17) located on the western coast of the Arabian Gulf (18). The Qatar FIFA World Cup 2022 welcomed 32 teams and was hosted across eight stadiums (19). Stadiums were constructed as some of the most eco-friendly and architecturally innovative stadiums with cooling technology capable of reducing temperatures within it by up to 20°C (36°F) (19). Qatar is home to around 3 million people (18) from around the world and approximately welcomed external fans equal to more than half of the country's total population. Certainly, hosting with such an enormous number of fans like the FIFA World Cup necessitate vigorous security measures to protect players, spectators, and residents.

The World Cup 2022 came with exceptional challenges being held against the background of Corona virus disease (COVID-19) pandemic. Qatar has one of the lowest COVID-19 mortality rates in the world. This could be due to the government's quick and comprehensive measures, which include adjusting public health measures based on the ongoing epidemiological surveillance system, strategic testing, COVID-19 awareness campaigns, and free vaccinations to the public (20). The government has also implemented strict travel regulations for individuals coming from abroad (21). However, other infectious diseases and resulting epidemics had become significant health threats around the time of this event, such as monkeypox (22) and Middle East respiratory syndrome coronavirus (MERS-CoV) (23). The risk of an outbreak of different infections would be even more significant in such events as the visitors were expected to be from more diverse backgrounds. In order to reduce the risk of communicable disease outbreaks during the World Cup, event planners in Qatar recommended conducting a thorough risk assessment prior to the event, and creating risk management/communication plans (24).

The literature reported that large sport events and other mass gatherings impose a risk in increasing the cases of COVID-19 and other infectious diseases (25, 26). No studies have reviewed the health risks and prevention of infectious diseases during sport mass gathering events; therefore, it needs to be thoroughly reviewed in order to be able to develop effective risk management/communication plans. This scoping review will map the available literature regarding the risk factors of infectious diseases including COVID-19 and strategies followed for prevention in previous world cups or sports events to provide recommendations for future FIFA World Cups and other sports mass gatherings.

2. Methods

This review was conducted by employing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) (27). During the review, we followed these steps: Identifying the research question, identifying the relevant studies, selecting the studies, extracting the data, collating, summarizing, and synthesizing the results.

2.1. Identifying the research question

The overarching research question for our review is: what are the strategies followed for the prevention of infectious diseases in sports mass gatherings? To address the main question, we also identified the following specific questions:

• What are the risk factors for infectious diseases from previous world cups or sports events with mass gatherings?

• What are the recommended strategies to be followed for the prevention of infectious diseases before, during, and after the sports mass gatherings?

2.2. Identifying the relevant studies

A systemic search was performed using PubMed, Embase, Web of Science, SCOPUS, SportDiscus, and Google scholar. These databases were searched without restrictions to reclaim any publications related to our research question in the period between 2010 and 24 January 2022. The search strategy included three main strings viz “communicable disease” AND “sport” AND “setting” as keywords for each string were used when building the search strategy. The combination of keywords used were (world cup OR sport OR stadium) AND (infectious disease OR communicable disease OR virus) AND (mass gather OR crowd). Table 1 describes the search strategies used to gather the articles from the mentioned databases. To assure not missing any publications related to our purpose, google scholar was further searched, and the reference lists of the selected articles were also screened for articles that might have been not captured from the initial search of the databases.

2.3. Selecting studies

Any study investigating infectious diseases in the previous FIFA World Cups and other sporting events with mass gatherings was eligible to be included. The first two authors and the corresponding author independently screened titles and abstracts of the citations retrieved from the search. Then, these articles were divided among the same three authors to assess full texts of the relevant records independently. During the study selection and assessment process, the three authors would meet to resolve any conflict and reach an agreement.

Inclusion criteria:

• Articles covering sports mass gatherings.

• Peer-reviewed articles published in the period between 2010 and 24 January 2022.

• Articles covering other mass gatherings, but/or with recommendations for infectious disease prevention in sports events.

• Articles addressing risk factors of viral infectious diseases and/or protection and prevention of infectious diseases.

• Review articles providing recommendations for infectious disease prevention in sports events and other mass gatherings.

• Articles on infections that are transmitted through air, direct contact, or droplets.

• Articles published in English.

Exclusion criteria:

• Small-scale sports events.

• Articles addressing risk factors irrelevant to viral infectious diseases.

• Articles addressing infectious diseases caused by pathogens other than viruses.

• Reports, book chapters, and conference papers.

• Articles on vector-borne disease.

2.4. Extracting the data

A priori identified spreadsheet was developed for data extraction. Data were reported in two tables: Table 1 reported the characteristics of the included studies and Table 2 reported the strategies and recommendations for infectious disease prevention pre, during, and post sports mass gatherings events. Specifically, the following information was included in Table 1: the first author of the study, publication year, country, article type, setting of the study, population description, type of sport, and type of infection. While the second table included the following information: risk factors of infectious diseases, strategies that are recommended to be followed before, during, and after the sports mass gatherings to prevent infectious diseases, and general recommendation for infectious disease prevention in sports mass gatherings.

2.5. Synthesizing the results

In our review, we clustered the infectious disease prevention strategies into three stages: pre-event, during the event, and post- sports event mass gatherings. Description of the scope of literature was presented in a model according to the various strategies and recommendations followed to prevent infectious diseases in various stages of the planning, implementation, and follow-up after the sports mass gatherings are finalized. The model also showed how these strategies of the three stages are impeded in different three contexts that would support their implementation, monitoring and evaluation. These contexts are community/ public social responsibility, preparedness of the health care system, and the regulations/policy/guidelines of public health authorities and other partners.

3. Results

Following the mentioned search strategy, 158 records were retrieved from the mentioned databases search. The remaining records, after removing the duplicates, amounted to 109 records. After screening the titles and abstracts, 23 were excluded; the remaining 86 full-text articles were assessed for eligibility, and 34 studies were reserved for this review. The PRISMA diagram demonstrates the selection process and clarifies the reasons for exclusion of other studies (Figure 1).

Figure 1

3.1. Characteristics of the included studies

The studies were divided by design into 11 scoping reviews (10, 12, 28, 30–33, 38, 45–47, 50), three cross-sectional studies (14, 40, 41), four editorials (8, 9, 13, 37), two series reports (16, 34), one randomized controlled study (15), one commentary (29), one summary of national surveillance data (11), one special communication (35), one comment (42), one report (43), one case study (44), one epidemiological study (48), one participatory surveillance (49), one letter to the editor (51), one prospective case-control survey (52), one epidemiological study (48), and two articles were not specified (36, 39). The majority of these studies reported their findings from one country, one study reported data from two countries, and 12 studies were not in specific countries. In 23 studies, the settings of the research were related to sports events, six studies looked at mass gatherings in general, four studies looked at two settings:

Hajj and sporting events or music arena events or mass gatherings in general and one study looked at the Hajj pilgrimage. The majority of studies have described populations in mass gatherings, and the rest of the studies have described athletes or/and travelers or/and the audience. In 11 studies, the types of sports that were described were multiple sports, in nine studies it was football, in one study it was baseball, while in 13 studies the type of sport was not specified. The type of infection that was addressed varied between studies. In 15 studies, they described more than one infection. The most common infection addressed in the majority of these studies was influenza and 12 studies were focused on COVID-19 solely. In six studies, there was no specific type of infection, while two studies described the Ebola virus or measles (see Table 2 for the characteristics of the included studies).

3.2. Risk factors of the infectious diseases' outbreaks in the included studies

In order to prevent the spread of infectious diseases through a specific event, several risk factors must be considered. In general, risks to travelers involve locally endemic infections that are unfamiliar to many travelers, or infections that are more likely to arise as a result of crowding related to mass events. In terms of risks to citizens, travelers carry pathogens that could initiate a local epidemic, such as the corona virus as well as influenza virus (13). Others included non-compliance with basic infection control and prevention standards such as poor hygiene, lack of sanitation, inadequate vaccination coverage, lack of immunity due to non-vaccination such as the fact that the majority of people who became ill with measles had not been vaccinated, close contact between the players, also the infection risky behaviors including touching the face and spitting (9, 12, 15, 28, 33, 38). Traveling is one of the most important factors in disease transmission particularly when visiting high-risk areas (10–13, 28, 29, 40), because the risk of disease transmission is across communities due to overcrowding, localized high population density (9, 12, 30, 34) and challenges in contact tracing due to the mobility of attendees with communicable diseases (8, 30). In addition to group identity, physical setting, climate, population participating in the event, and potential infections, crowd behaviors at live events may be affected by behaviors before and during the pandemic (34, 46), a study has also shown that transmission is most intense from February to June, with influenza peaking in June and July (14). In addition, one of the most critical factors is the ability to respond effectively and quickly to outbreaks and other emergency situations (41).

3.3. Pre-event strategies

In our review, several studies documented the pre-event preparations in worldwide sports events during epidemics. The immunization and vaccination for hepatitis A&B, yellow fever, rabies, mumps, measles, rubella, and influenza were recommended strategies, in which travelers should be encouraged to visit a health-care provider 4–6 weeks before travel to manage any risk through vaccinations (8, 9, 11–14, 31, 34–38, 47, 48, 50). Other strategies included educational messaging through targeted media and communications prior to the matches (8, 44), infection control practices such as hand hygiene, cough etiquette (8, 31, 36, 38, 44), pre-travel consultation (8, 10, 12, 52), and advice on the correct timing and use of personal protection measures (10, 36), self-isolation and quarantine for new arrivals or symptomatic individuals (31), physical distancing measures and regular COVID-19 testing were proposed with strict adherence required from staff, players, coaches, and others (28, 44), as well as travel precautionary measures including COVID-19 test certificates, quarantine, digital apps (12, 44), and travel restrictions by reducing flights and public transport (29).

The recommendations for the athletes, staff, and others included testing all athletic activities including pre-events, training sessions in the recognition and management of communicable diseases (12, 28, 36, 41), informing the travelers about their role in transmitting or preventing the transmission of the disease (11), as well as providing health education psychology supporting materials for athletes. Another study recommended that employees could operate from home to avoid having direct contact with athletes (15). Some studies mentioned the contribution of efforts to create multidisciplinary surveillance (40), and public health risk assessment to follow the principles of risk analysis, surveillance, and reporting in order to enhance public awareness of public health concerns (16, 42, 52), and how to inform about the health situation and any relevant advice and recommended actions (42). See Table 3 for summary of the pre-event strategies.

3.4. Strategies followed during the event

During the sports events, numerous studies identified particular recommendations as shown in Table 3. These recommendations were basic preventive measures among football players, coaches, staff members, and the general public (37, 44, 46) including the use of masks (46, 47) and the practice of social/ physical distancing (29, 31, 46, 47) with adequate hand hygiene (37, 46, 47), coughing etiquette (37), and contact avoidance (37, 47). In addition, a couple of studies were conducted among athletes to avoid sharing personal objects such as towels and water bottles (37), test athletics activities during the events (28), send weekly updates to remind all personnel on maintaining physical distance between individuals during and after training (15), and implement the organizational measures to increase the distance between dressing and showering athletes (37). Also imposing social distancing rules (31) through the physical distance between seats, specifying the number of attendees (44), limiting access and effective management of the flow of the people in and around the venue (46), and limiting some behaviors at live events such as singing, hugging, and jumping (46).

Murray and McCloskey both reported in 2020 about risk mitigation strategies such as staggering arrivals and departure, offering virtual or live–streamed activities, increasing the number of and access to handwashing stations, reducing the number of participants, or having a participant-only event without spectators, symptoms screening and testing, frequent diagnostic testing for rapid case identification, isolation of persons with positive test results and quarantine for close contacts, limiting travel to essential staff members, and prohibiting visits to gatherings of large groups of persons (42, 43). In addition, a study recommended identification of the disease through a mobile application by detecting the tone and strength of the cough, in which the accuracy of it is 70%, or by checking fever (39). Furthermore, the ministry of health's participation with the National Organizing Committee in daily all-hazards assessment report about the situation (36), enhancement of established systems by reviewing and collating daily incident, outbreak, and response reports (16), daily analysis of mortality data by all local health-protection teams (16), development of enact surveillance and disease reporting mechanism in order to identify infectious disease outbreaks during the event (33, 34) and assessing the frequency of infection-risky behaviors such as spitting, coughing (15) are recommended strategies during the event (see Table 3 for summary of the strategies recommended during the event).

3.5. Post-event strategies

In general, post-event recommendations include post-travel surveillance, particularly for infections with long incubation times (14), and testing athletics activities post-event (28). Countries must be prepared with a public health surge capacity and implement control measures to prevent infections from being exported back to their countries of origin by attendees (33), and in a study conducted in Hong Kong 2020, all personnel returning to their nation were obliged to electronically record their temperature and symptoms for 14 days, and any staff arriving from a COVID-19 impacted country was self-isolated at home for 14 days (15) (see Table 3 for summary of the post-event strategies).

3.6. General recommendations

Several general recommendations to prevent the spread of infectious diseases were suggested in some studies as shown in Table 3. Infection control measures recommendations include hand hygiene, using a protective mask, and social distancing (12, 34, 50), prompt isolation, and treatment of detected infectious cases which aims to prevent the spread of infections (34), adequate vaccination and recommended immunization (34), strict monitoring and screening of symptoms, widespread testing (15, 50), and minimizing the number of people congregated at one single location through closed competitions with no spectators, as well as unnecessary personnel present at a venue (15). Furthermore, a couple of studies considered enhancing epidemic intelligence to detect incidents efficiently (8, 10), implementing standard operating procedures for epidemic response (10), and developing community mitigation plans as general recommendations to consider (29). Implementation of protective and control measures such as risk, emergency, and crowd management, physical protective systems (31, 32, 45), and contact tracing for the audience (50, 51) all form an integral part of any sports event management. Moreover, other studies assessed the establishment of an appropriate routine health surveillance system in order to identify infections early (12–14, 16, 34, 36, 49) such as Syndromic Surveillance (16, 34), a collaborative approach between the ministry of health and other ministries, the committee and WHO to ensure rapid detection and containment of infectious diseases (33, 34, 36, 44), and enhancement of clinical, public health, and environmental microbiology laboratory capability and capacity (16, 34).

4. Discussion

To the best of our knowledge, this is the first systematic attempt to comprehend communicable disease risk in the context of previous mass gatherings sport. Several key findings were highlighted including the risk factors of different infectious diseases and prevention strategies that were clustered into three stages: pre-, during, and post-sport event mass gatherings.

Traveling continues to pose risks related to the prolonged close contact with people who may be carrying transmissible illnesses (53). Traveling results in increasing mobility, overcrowding and localized high population density, which impact the transmission of infectious diseases among communities. Another important risk factor is crowd behavior. In contrast to our findings, it's found that developing common identities between crowds can transform hazardous mass gatherings into a health-promoting event (54). This is explained by how behaviors are influenced by group identity, physical setting, climate, and individuals participating (46).

The majority of studies included has identified pre-event recommendations. This indicates that pre-event recommendations are the first line of defense and, if implemented correctly, can reduce the risk of COVID-19 transmission. Supporting our findings, pre-event vaccination and travel medicine measures were successful in preventing epidemics of influenza A H1N1 during the worldwide pandemic in 2009 at the Hajj and the Asian Youth Games in Singapore (55, 56). Immunization is a critical component of travel medicine, particularly for high-profile events such as the World Cup. Additionally, employing health communication by generating and spreading educational materials in the press for the public. Similarly, a study included all of FIFA's risk management published articles from 1994 to 2011 showed the effectiveness of risk communication in any risk management strategy (57). They provided the residual risk levels associated with certain risk factors to stakeholders in an appropriate and accessible manner, allowing informed critical discussions (57). Communication and collaboration are crucial among public health authorities within the host country as well as across participants' home countries to ensure the spread of health information among visitors.

During-event recommendations normally receives the most attention when events take place. According to the findings of this scoping review, adequate respiratory hygiene measures and practices, as well as rapid responses from public health authorities to detect infectious cases, was found to lower the likelihood of outbreaks. Similar to these findings, a study done to evaluate the effect of preventive measures, including face masks, stadium capacity, and capacity proportion on the infection risk has found that with the introduction of face masks and hand washing methods, the infection risk was decreased by 86–95 percent (58). This demonstrates that violations of COVID-19 recommendations, including not wearing masks, social distance, and self-isolation, will have a considerable influence on the total number of COVID-19 cases, and other respiratory diseases.

Only few studies considered taking actions after the end of sports events, which is considered as a limitation in the preparedness process. It was found that post-travel infections become apparent soon after, with 43–79% of travelers becoming ill with a travel-related illness (59). In addition, global surveillance after the event can be used as a guide to detailed travel history during every patient encounter (60). A study conducted in Brazil found that skin problems, diarrhea, and febrile systemic infections are most prevalent in returned travelers (14). Similar to our findings, a study reported that despite the success with mitigating spread of diseases, the returning Saudi pilgrims who visited pilgrimage sites in Iran and Iraq were early sources of COVID-19 spread, contributing to 150,000 cases (61). Thus, applying post-travel surveillance would contribute to COVID-19 mitigation.

In addition, some general recommendations were suggested. These recommendations include increasing the speed and accuracy of existing surveillance capabilities, developing active surveillance systems, conducting a detailed risk assessment to prioritize infections, and having the capability to receive and evaluate data quickly are all diverse ways to improve surveillance during sports mass gatherings (62). Even though the enhancement of the surveillance system might be relevant to the sports event itself, it should benefit the host country's public health infrastructure eventually (63).

4.1. Implications and recommendations for practice represented in a model

Based on this review, a model was constructed to represent the strategies followed to prevent infectious diseases in various stages of the event: pre-event, during the event, and post-event, and to describe the scope of literature. The model also shows how these strategies are related, and are supporting each other to achieve the goal of preventing infectious diseases during the three stages of the event. In addition, the model reflects on how these strategies are impeded in different three contexts that would support their implementation, monitoring, and evaluation. These contexts are the public social responsibility, preparedness of the health care system, and the regulations/policy/guidelines of public health authorities and their partners (see Figure 2).

Figure 2

It is recommended that tourists have a pre-travel consultation before traveling to consider suitable health and safety precautions, including vaccination. Since COVID-19 is still not over and there is a concern of emergence of new strains of SARS-CoV-2 virus, it is recommended that athletes, visitors, and citizens get the full vaccinations; provide them with a passport containing information about previous infections, results, testing, and vaccination status; and provide free rapid test centers for fans near each stadium, as well as directly matching these results in the spectators' passport. Authorities need to have an agreed preparedness plan, strengthen health emergency preparedness, and ensure the maintenance of precautionary measures for containing infectious diseases including COVID-19. Hospitals should be assessed with adequate workforce, providing appropriate training for the medical staff, and having multilingual services to address the language barrier are also essential. Event organizers should agree with the public health authority on how participants and the local people will be kept informed about the health situation, key developments, and any relevant recommended actions. Following these strategies would enhance the effective implementation of the other precautions during and after the effect.

Public health authorities and their partners authorities are advised to follow critical proposed recommendations, including implementation of the syndromic surveillance systems, or enhancing surveillance systems, disseminating public health messages specific to infectious diseases, and educating participants on prevention measures of these diseases. The public plays a vital role in mitigating any pandemic. Hence, enhancing social responsibility is a key to prevent outbreaks or combat the virus during events with mass gatherings. Low et al. illustrates that individuals' social responsibility actions are a result of the interaction between perceived infection risk and societal role responsibility. Public perception is critical in improving health risk communication, fostering public trust, and collaborating with the government's outbreak prevention efforts. Members of society can be empowered through organizations emphasizing their roles during the epidemic and recommend certain actions.

4.2. Implications for future research

This study will serve as a roadmap for preparedness for mega sports events in order to prevent infectious disease outbreaks. Our review reflects on a clear gap in quantitative evidence and highlights the need to conduct the quantitative assessment during the different stages of the event. Further observational research on post-sports mass gatherings is needed to explore various prevention strategies that should be implemented for this stage. In addition, it would be remarkably interesting to conduct qualitative research to study the perception of the public the World Cup hosting countries on social responsibility toward the World Cup, which may help improve future prevention and control efforts.

4.3. Strengths and limitations

This scoping review is the first to explore COVID-19 recommendations in the setting of the FIFA World Cup. The review includes a comprehensive search strategy and the most recent compilation of relevant up-to-date data from 2010 to January 24, 2022. There were no restrictions put on the study design, allowing for a broad exploration of peer-reviewed articles. This scoping review, however, has some limitations. A major limitation of this review is that the majority of the included studies are reviews and qualitative research, which reduces the quality of the evidence provided. Evidence of quantitative assessment is lacking in this scoping review and the quantitative contributions of the proposed specific recommendations in the prevention and control of infectious diseases cannot be certified, thus this is an urgent call for conducting quantitative research to provide evidence for effective planning for these events.

The included articles were not checked for validity in line with the scoping analysis approach, which is a less relevant method in scoping reviews. Furthermore, by excluding gray literature and non-English language literature, some bias may have been introduced.

5. Conclusion

The current scoping review identified a variety of studies and review articles that emphasize key findings, in order to develop a mitigation strategy for dealing with COVID-19 and other infectious diseases within the context of the FIFA World Cup The risk of COVID-19 infection and other infections among spectators at mass gathering events was reported. This review provides fundamental pre, during post-event recommendations to narrow and ideally achieve a “virus-free” event. The constructed model is reflecting on the importance of the involvement and empowerment of the public by enhancing their social responsibility and the coordination between the healthcare system, the ministry of public health, and other stakeholders for infectious disease prevention during the FIFA World Cup.

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