The experience of Qatar in hosting the Amir Cup football final 2020 and the execution of preventive measures to reduce the spread of the COVID-19 infections among fans are described in this paper. Qatar is one of the first, Middle Eastern countries to allow the return of elite football with spectators. It was a massive challenge considering that the WHO advisory suggested the risk of hosting an event involving mass gatherings during the active phase of the ongoing pandemic to be of very high-risk 18 19. During this unprecedented situation, the capability to safely resume the sporting events depends on implementing the safety measure for risk mitigation towards the spread and/or reinstatement of COVID-19, especially at times when there are high chances of newer waves of COVID-19 cases. To our knowledge, the current study is one of the first to report the consequences for the spectators of a controlled resumption of competitive sport.
The Amir Cup event was a success, with 16,000 spectators in attendance in the same stadium. This was the first time such an initiative was taken to welcome a huge number of spectators in a country that has not yet been deemed COVID-19-free. At the start of the pandemic, Qatar was one of the countries with the highest infection rates per million population (the infection rate peaked at 1.27% on 27 May 2020 with about 35,634 active cases for a population of 2,807,805), but by 18 December 2020, it had dropped to about 0.07% (2090 positive active cases among the entire population). Under such epidemiological conditions, our study found that resumption of professional football under strict adherence to the return to competition protocol and a gradual return of a small number of spectators to stadiums were not associated with COVID-19 infections.
Since the COVID-19 pandemic began in 2019, there have been few reports of high transmission of COVID-19 cases during athletic events other than soccer. Outdoor events with large crowds, such as professional football, can behave as super-spreaders of an airborne virus like COVID-19 20 21. There is a lack of evidence about the impact the attendance of fans under a controlled environment can have on mitigating the super-spreader nature of mass sporting events during the COVID-19 pandemic 20. Ahammer et al. 3 and Cardazzi et al. 22 determined the impact of sporting events as super spreaders. Ahammer et al. looked at mass indoor events in the COVID-19 pandemic and found that these events led to around 380 more COVID-19 cases and 16 more deaths per one million people in the country. During the Amir cup − 2020 final event, none of the players returned with a positive result for COVID-19 infection. This is remarkable because stadiums present unprecedented challenges to COVID-19 mitigation strategies due to the involvement of many factors such as the sheer size of attendance (50%), seating proximity, high level of contact between athletes, and the spectators' intensity.
A study with similar intent looked at the impact of the virus's spread last April from English football matches played in February and March 2020, before the first national lockdown. The evidence suggested that regardless of how full the stadiums were, the health outcomes following an English football match in March were consistent; for every 100 000 people in the same local area, there were 6 COVID-19 cases, 2 deaths, and 3 overall deaths 23. Subsequently, the UK government postponed the planned reintroduction of spectators in September 2020, with resumption set to begin on October 1st, 2020. This decision was made in response to the greater COVID-19 restrictions in the UK, after various clubs held test events with approximately 2,000 people 21. However, due to the changes in the situation with COVID-19, the govt instructed sporting bodies that spectators would not be allowed into stadiums until at least March 2021.
In contrast to the scenario mentioned above, our experience showed that if a multi-layered protection strategy involving physical separation, disinfection, communication, and crowd control is strictly implemented, professional football with spectators in stadiums can be successfully re-booted in the face of the COVID-19 pandemic.
Our findings are consistent with those from the German Bundesliga professional football league. They reported a successful return of the game under a controlled environment with a diminished risk of viral transmission 11. Indeed, Schumacher et al. observed that during the COVID-19 pandemic, the Qatar main football leagues (League 1 and 2) were restarted, with no indication of COVID-19 transmission from player to player during training or match play. However, both the abovementioned events were organized without spectators.
In our setting, matches were played with 50% attendance. Even though studies have shown antigen testing to be highly accurate in detecting positive cases, no factual inference can be drawn from our data regarding the danger of SARS-CoV-2 during match play involving spectators. Nonetheless, there is a higher possibility of false-negative outcomes. The latter is likely to raise worries about testing. Any positive antigen result will result in a PCR confirmation test, although a false negative might conceivably allow the undetected spread to occur. As a result, spot PCR validity testing on negative antigen samples are required as a precaution. When fans are present at sporting events, daily testing should be conducted as an additional layer of surveillance safety. However, we must acknowledge that even in countries where the surge of COVID-19 infections has initially been contained, the subsequent wave of new infections involving new strains has been reported 24 25. In such a scenario, the return to play protocol which ensures more robust infection mitigation measures assumes greater importance to create the safest possible environment for the return professional football with spectators.
Strengths and Limitations: One of the strengths of our study is that we analysed the health status of the spectators before and after the football event based on PCR based surveillance and followed up on the spectators' health status for four weeks post-event. We assume that spectators who tested positive for COVID-19 after the final event may have been missed by the screening protocol or were infected from other sources after the event. To mitigate this, we recommend performing rapid antigen tests within 24–48 hours before sports events. A possibly positive spectator who got the virus after testing might be infective to other spectators after 2 or 3 days. So even if he has slipped through the net, the other spectators may still be relatively secure because the positive spectator is not infective yet 62627. Also, we recommend that the players and match officials to undergo rapid antigen test before the last training session prior to the game. Any suspected positive cases to be validated by PCR. The antigen rapid test has the advantage of requiring fewer logistics, being less expensive, and providing better accuracy regarding the contamination risk before the game, i.e. 24 hours instead of 48–72 hours, when there is a chance of players contracting an infection following the test. We caveat our analysis by noting that the stadium access and egress routes can be adapted. Some of the opportunities for the spread of an airborne virus such as SARS-CoV − 2 could be mitigated.
Lack of asymptomatic surveillance and voluntary reporting are the two important limitations of the study. Finally, this study took place prior to start of extensive vaccination drive and the emergence of the SARS-Cov-2 Delta strain in Qatar.
Even though, the rate of COVID-19 positivity among spectators in our study was found to be very low, our results suggest extreme caution in returning to unrestricted spectator attendance at football matches. Nonetheless, the current article's conclusions should only be applied to outdoor settings, such as football games. The successful resumption and completion of the Amir Cup-2020 final acted as a template for the few other football tournaments involving international participants and spectators to be held successfully in Qatar. The game's safe and infection-free hosting marks an important milestone in Qatar's preparations for the FIFA World Cup. It provides an opportunity to test its operational plans further and ensure its readiness for football's showpiece event in 2022 amidst the world's uncertain epidemiological circumstances. Lastly, a recent study showed that the psychological support for sportsmen during the pandemic should highlight the coping strategies and sense of coherence; this issue was not addressed in our local experience, but it deserves further studies 28 .