Swimming during COVID-19: Operational recommendations and considerations for South African swimming venues

Swimming is one of the most popular recreational activities in South Africa. Since the emergence of the Coronavirus disease 2019 (COVID-19), South Africa imposed one of the strictest lockdown measures to contain and control the spread of the virus. These measures included the closure of gyms, fitness centres and swimming pools across the country. However, as the restrictions begin to ease, it is important to consider how swimming facilities can reopen whilst simultaneously ensuring appropriate measures are in place to reduce COVID-19 infections. Outlined are recommendations and considerations for swimming facilities in South Africa. Currently there is no evidence to suggest that COVID-19 transmission to humans is possible through water, making swimming one of the safer options for physical activity indoors. However, participation is still not without risk and compliance with government mandates and public health officials take precedent over the recommendations outlined in this article.

The current understanding of COVID-19 is continually advancing as research around its prevention and treatment proceeds. [9] However, based on what is already known and working within the current public health guidelines, it is possible to define a framework of risks and outline potential preventive measures for sport. It is important to note that while COVID-19 is exceptionally contagious in most enclosed environments, this might not be the case in swimming pools. [10] According to epidemiological data presently available, there have been no reported cases of COVID-19 from swimming pools or through the use of water. [11] As swimming is such a popular sport, prevention of COVID-19 transmission in swimming pools must be examined. Although these environments may present a lesser risk of infection that others, caution is still necessary regarding the operation within public health recommendations and guidelines. [12] This includes respecting current regulations and recognising that the understanding of the virus may change rapidly. Within this context, the government of South Africa already has specific requirements for maintaining swimming facilities regarding hygiene, sanitation, disinfection and good practice. [13] Recently, the South African Sports Medicine Association (SASMA) released a position statement for the resumption of sport within the country. [3] The statement outlines five guidelines regarded as a minimum to be incorporated into any post-COVID-19 return-tosport strategy. These include 1) education, 2) preparing the environment, 3) risk stratification of the specific sport, 4) risk stratification for the participants, and 5) the practical implementation of mitigating measures of different sports. [3] Further, Swimming South Africa has also drafted COVID-19 compliance directives [14] which outline the guidelines and recommendations for the return to competitive swimming, training and learning to swim.
With these in mind, the potential safety considerations for swimming facilities are as follows: 1. Constant monitoring of the epidemiological status locally and countrywide. 2. Defining specific risk assessment based on general guidelines for the prevention of COVID-19. This includes the facility and building structure, the swimming pool area, as well as the changing rooms and service areas. This is the specific attention paid to the maximum occupancy for minimising transmission and hygiene protocols. 3. Acquisition and availability of personal protective equipment for staff, users and guests. This includes adherence to the Department of Health guidelines [12] , including physical distancing, mask mandates and access to soap and hand sanitisers. Key operational measures to ensure the safe function of swimming facilities should include those specifically outlined by the Department of Health [12] and other public health specialists. These measures (see below) are subject to change and largely dependent on the specific facility in question.
1. The organisation of effective access control to the facility, swimming pool area and change rooms for both staff, users, and visitors. Although already in place at most facilities, there should effective screening of COVID-19 symptoms prior to arrival at the venue and explicit prohibition of those who are likely to have COVID-19 symptoms, are awaiting test results for the virus or have recently come into contact with anyone who has tested positive for the virus. 2. This can be done through a self-assessment toolkit. [12] a. iii. Having a chronic (long-lasting) health condition iv. Regularly going to a hospital or healthcare facility for treatment c. Being in close physical contact with someone who currently has COVID-19 (closer than one metre away from the infected person or in contact for more than 15 min, or medium risk >one metre or less than 15 min contact) [15] in the previous 14 days. Close physical contact with someone who currently has COVID-19 means any of the following: i. being less than two metres away in the same room, workspace, or area ii. living in the same home iii. being in the same classroom 3. Within the exercise facility and in the pool, there must be encouragement for interpersonal distancing. This can largely be achieved through scheduled reservations, work shifts, one-way routes, or other means to prevent crowding within shared spaces. In the pool, it is important to limit a single person to a single lane. If not currently present, lane lines should be implemented with sufficient distance between them to maintain interpersonal separation. 4. Facilities should strive to assure mandated water quality levels through appropriate disinfection and hygiene requirements. Procedures should outline clear minimal requirements, including optimal residual disinfection activity and pH levels. Water management should be addressed through local and country-specific by-laws. Facilities should have in place effective and up-to-date water safety plans. 5. As COVID-19 is currently known to be transmitted through the air, indoor facilities should ensure adequate air quality and microclimates aiming for maximum safety. It is not sufficient to only adhere to the minimum required levels. Facilities should consider the best possible methods for achieving air exchange, internal circulation, and ventilation. 6. As recommended by public health officials, facilities should establish routine and appropriate protocols to ensure the sanitation of common areas, changing rooms and the pool area. Sanitation should be done on a frequent basis with greater attention paid to high touch areas such as door handles, handrails, and communal waiting areas. Sanitation should be conducted within the already available guidelines. Disinfection and cleaning protocols must be clearly defined and routinely conducted with periodic inspection to ensure correct execution and effectiveness. 7. Facility staff, users, and visitors must acknowledge the assumption of risk when utilising the swimming pool. Although the recommendations above may assist in the mitigation of transmission of COVID-19, it is essential to understand that no activity is risk-free. Therefore, a consent or waiver document should be in place prior to use of the swimming facility.

The way forward
Although the above recommendations may assist with the mitigation of risk associated with a highly communicable infection like COVID-19, these recommendations should be considered as an addition to compliance to government and public health mandates. Appropriate adherence to the recommendations and bylaws should support efforts to reduce possible viral outbreaks, whilst simultaneously giving the public access to physical activity venues. [5,6] Whilst caution is still encouraged, the Italian Istituto Superiore di Sanità (National Health Institute) recently stated that there is no evidence that COVID-19 can be spread to humans through the use of swimming pools or whirlpools [6] , further supported by the Centres for Disease Control and Prevention (CDC). [11] If disinfection with chlorine is done correctly, in conjunction with adequate maintenance, the Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2) can be inactivated, reducing its infectivity and transmission. [10] Previously, SARS-CoV-1 was completely inactivated in wastewaters by chlorine (10 mg/L for 10 minutes with a concentration of free residual chlorine of 0.5 mg/L or with chlorine dioxide 40 mg/L for 30 minutes with a residual free chlorine concentration of 2.19 mg/L). [10] Therefore, swimming may be one of the safer exercise activities the public can undertake as long as strict protocols are observed. Nevertheless, independently from whether COVID-19 is transmissible or not in water, the recommendations should follow the general guidelines outlined by National and International Public Health agencies. A swimming pool is not only the water, but also a venue where people aggregate and are in close contact with each other both before and after swimming. Moreover, it is important to note that other risks are involved when travelling to facilities i.e. public transportation, which may also increase risk of COVID-19 exposure. It is necessary therefore to highlight the guidelines for swimming and pool venues should be done should be done within the context of the general guidelines of resumption of sport in South Africa. [3] Conclusion Finally, the recommendations and considerations outlined within this commentary should assist owners and operators with reopening various facilities around the country. It is suggested that facilities employ a dedicated Compliance Officer whose sole task is the monitoring, evaluating, and organising the various preventative measures and their implementation.

Disclaimer
This document has been compiled as a guide for the safe return to swimming and should be used only as a guideline and within the greater context of national and international recommendations. It is still the responsibility of organisers, operators, and administrative staff to ensure that facilities for swimming and training are compliant with directives by the WHO, NICD and DOH, and updates should be adhered to in a timeous manner.
This document is not a tool to return to sport prematurely but should be used aligned with the statutory guidelines (which may change constantly and differ from area to area).

Conflicts of interest and source of funding:
The authors declare that they have no conflict of interest and no source of funding.
Author contributions: LH conceptualised, designed, drafted, and prepared the above manuscript. PTN and BK critically revised and contributed to the manuscript.