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Updated: November 24, 2020

What is the current evidence regarding transmission of SARS-CoV-2 through physical fitness facilities? What precautions can be taken to minimize risk?

Summary

The following is a brief summary of the best available evidence from trusted sources that provides high quality information on the current evidence regarding transmission of SARS-CoV-2 through physical fitness facilities and the precautions that can be taken to minimize risk. No published evidence syntheses or systematic reviews were found to answer this question. However, three national guidelines, one provincial guidance, one regional guidance, one municipal guidance and two single studies were used in this REAL note. For additional information about each of the sources, see the Table below.  For additional information about each of the sources, see the Table below.

As per the Government of Canada, COVID-19 spreads from an infected person to another via respiratory droplets and aerosols (created by coughing or shouting) that come into direct contact with another person’s mouth, nose or eyes, or indirectly by touching surfaces with the virus [3]. Further, most transmission occurs indoors, and risk increases in crowded spaces, where there is poor ventilation, prolonged contact with others, and where there is singing, shouting or heavy breathing – as in exercise [3]. General public health guidance is to wear a mask indoors, wash hands frequently, limit prolonged contact, and stay at least 2 meters or 6 feet away from others outside your household. The following presents what is known about fitness facility contexts [3]. Overall and to date, there is limited evidence regarding how to eliminate the risk of transmission, and current guidance supports taking precautions to reduce risk. According to one study, precautions for frequent gym users may include being tested (where possible) and closing gyms where appropriate [7]
 
In the Government of Ontario’s Guidance for facilities for sports and recreational fitness activities during COVID-19, it recommends that instructors for indoor fitness classes should use microphones to limit shouting and movement around the class, and participants should not sing along or shout [4]. Additionally, the Eastern Ontario Health Unit Sport and Activity-specific Considerations for Facility Operators and Organizers guidance recommends the following: 1) avoiding the potential for gatherings before and after classes; 2) altering programs that require significant movement in order to maintain distancing; and 3) removing unused equipment to make more space [5]. For high intensity classes (e.g., spin and dance classes), a minimum of 3 metres of distance between individuals should be achieved, and physical barriers should be installed [5].  
 
In its Playing Sports guidance, The Centers for Disease Control and Prevention (CDC) emphasizes the use of masks where possible, especially for indoor activities, close-contact sports and situations where voices are raised [2]. If mask use is not feasible (i.e. during high intensity activities, like running where wearing a mask may cause difficulty breathing), activity should be done in a location with maximal ventilation and air exchange [2]. The Wear a mask to reduce COVID-19 transmission while exercising at the gym: belief or evidence-based? study states that surgical-type masks can reduce 85% of infections of the virus, and that this capacity significantly declines within 15 minutes of exercise due to increased moisture produced by hyperventilation and sweating, and it is therefore recommended to change a mask every 15 minutes during intense activity [7].  
 
The authors of a study on the Cardiopulmonary Exercise and the Risk of Aerosol Generation While Wearing a Surgical Mask note that a minimum of 6 air changes per hour is recommended in indoor fitness settings [8]. The CDC notes to consider adding high efficiency particulate air (HEPA) filtration units to poorly ventilated areas, and if using free standing fans, ensure that air is not directed from one patron to another [1]The Government of Ontario and Toronto Public Health recommend the following: 1) increasing air-exchanges by maximizing outdoor air ratio of HVAC systems; 2) opening windows and/or doors; 3) avoiding recirculation of air; 4) frequent maintenance of HVAC systems; 5) using highest efficiency compatible filters; 6) ensuring HVAC inlet/outlet areas are clear; and 7) not using pedestal fans which can blow exhaled droplets to others [4,6].  
 
The CDC, the Government of Ontario, the Eastern Ontario Health Unit and Toronto Public Health provide the following guidance for gyms and fitness facilities: 1) enforce the use of masks (except while engaging in specific types of physical activity); 2) increase the frequency of disinfection of the facility and equipment between use and remove items that are difficult to clean; 3) ensure a physical distance of at least two metres is maintained between all individuals, facilitated by the modification of equipment arrangement and visual cues/markers and signage; 4) enforce a distance greater than two meters in areas where patrons are engaged in high intensity exercise; 5) suspend the use of towel services; and 6) install physical barriers at front desks [1,4,5,6].  

Evidence

What‘s Trending on Social Media and Media

In October, 2020 a Hamilton, Ontario spin studio, SPINCO, had a COVID-19 outbreak infecting at least 72 people. SPINCO experienced significant transmission despite following public health guidelines. The fitness studio has announced it is temporarily closing its spin studios in regions of Ontario. Find the CBC article here. 
 
CBC released a news article on October 15th, 2020 on the risk of superspreading at gyms. Strenuous activity is a high-impact activity that can lead to heavier breathing causing droplets to expel from peoples’ mouths at an accelerated rate and being propelled farther distances. Dr. Ilan Schwartz suggested that spin classes may pose more risk due to the rapidly spinning wheels propelling aerosolize droplets further distances. Not all types of fitness classes will present the same dangers. 
 
In Ontario, popular fitness chains ask residents from COVID-19 hotspots not to travel to gyms in other regions. On October 15th, 2020, LA Fitness started to freeze memberships for members located in higher transmission areas. This means members will not be billed during the time of this closure. Staff at an LA Fitness location in Vaughan said employees were checking ID at the door and turning people away who do not reside in York Region Find the article here

Organizational Scan

UKactive released an article stating that COVID-19 had low prevalence in a gym environment in England when following strict government guidelines during reopening. Within the first three weeks of the reopening date, from July 25 to August 16, facilities only reported 17 positive cases with 8 million people visiting. Regular exercise has been shown to improve a person’s ability to regulate the immune system, which is essential for avoiding severe COVID-19 symptoms [9]
 
The International Health, Racquet, and Sportsclub Association analyzed millions of member check-in data across 2,873 gyms, sports clubs, and boutique fitness centres over three months and found fitness facilities are safe and are not contributing to the spread of COVID-19. Click here for more information [10]

Review of Evidence

Resource Type/Source of Evidence Last Updated
COVID-19 Employer Information for Gyms and Fitness Centers
— CDC: Centers for Disease Control and Prevention
National Guidance

The CDC recommends the following controls:  1) facilitate physical distancing through rearrangement of equipment, adding physical barriers and visual cues; 2) provide hand sanitization stations; 3) ensure proper ventilation (add HEPA filtration units for poorly ventilated areas, and if using fans, ensure that air is not directed from one patron to another); 4) disinfect all equipment between patrons and remove hard to clean items; 5) limit the number of people in the facility; 6) limit locker room access to restrooms only; 7) limit access to common areas (e.g., break rooms, waiting areas); and 8) close water fountains except for touch-less refill stations. 

Last Updated: October 26, 2020
Playing Sports
— CDC: Centers for Disease Control and Prevention
National Guidance

The CDC states that when using an indoor facility, previous users should leave the facility and facility should be cleaned/disinfected where possible before entering. The CDC emphasizes the use of masks at all times, especially for indoor activities and situations where voices are raised. If mask use is not feasible, activity should be in a location with maximal ventilation and air exchange. Face shields are not recommended as substitute to masks. Sharing of equipment/items should be avoided.

Last Updated: August 6, 2020
COVID-19: Main modes of transmission
— Government of Canada
National Guidance

The Government of Canada states that COVID-19 spreads from an infected person to another via respiratory droplets and aerosols (created by coughing or shouting) that come into direct contact with another person’s mouth, nose or eyes, or indirectly by touching surfaces with the virus. Most transmission occurs indoors, and risk increases in crowded spaces, where there is poor ventilation, prolonged contact with others, and where there is singing, shouting or heavy breathing. General public health guidance is to wear a mask indoors, wash hands frequently, limit prolonged contact, and stay at least 2 meters away from others.  

Last Updated: November 4, 2020
Guidance for facilities for sports and recreational fitness activities during COVID-19
— Government of Canada
Provincial Guidance

This guidance provides the following recommendations: 1) maintain physical distancing of 2 metres at all times; 2) consider extending business hours and provide pre-booking to stagger times and disinfect between bookings; 3) decrease touch points (e.g., contactless check-in); 4) suspend use of hand dryers in favour of paper towels; 5) consider suspending rental services; 6) patrons should arrive appropriately attired and exit once activity is completed; 7) limit use of shared equipment or activities; 8) install barriers between equipment and at service counters; and 9) consider a physical distance of >2 metres for high intensity equipment and exercise classes. 

Last Updated: October 9, 2020
Sport and Activity-specific Considerations for Facility Operators and Organizers
— Eastern Ontario Health Unit
Regional Guidance

This guidance provides suggestions for different fitness settings.   For personal training: 1) use virtual training; 2) maintain physical distancing in the waiting room; 3) advise people to arrive near appointment times; and 4) avoid touching clients.   For group classes: 1) wear microphones to reduce shouting; 2) discourage singing and shouting; 3) mitigate potential for gatherings before/after classes; 4) alter programs requiring significant movement so as to maintain distancing; and 5) remove unused equipment to make more space.   For indoor tracks: 1) use every second lane; and 2) suggest runners and walkers travel in the same direction on the track.  

Last Updated: November 24, 2020
COVID-19 Guidance for Sports & Recreational Fitness Facilities
— Toronto Public Health
Municipal Guidance

This guidance suggests the following: 1) manage lines outside and within the facility, (e.g. use signs and floor markers); 2) mandate that staff must wear masks and eye protection; 3) develop a protocol on wearing masks as per the City of Toronto bylaw; 4) use tap cards rather than PIN for payments and items such as magazines and pens should be removed from lobbies (front desk, sales, and registration); 5) increase circulation by maximizing outdoor air ratio of HVAC systems, or opening windows; and 6) ensure frequent cleaning of high-touch surfaces (e.g., doorknobs, railings, etc.) at least 2x daily.  

Last Updated: October 20, 2020
Wear a mask to reduce COVID-19 transmission while exercising at the gym: belief or evidence-based?
— Silveira et al.
Single Study

This study notes that conventional masks can reduce 85% of infections of the virus, but this capacity significantly declines within 15 minutes of exercise due to increased moisture produced by hyperventilation and sweating. It is not feasible to change masks every 15 minutes to maintain mask efficiency. The most effective way to contain the virus would be to keep gyms and fitness centers closed. COVID-19 testing should be frequently required by establishments to ensure a safe indoor environment.

Last Updated: October 20, 2020
Cardiopulmonary Exercise and the Risk of Aerosol Generation While Wearing a Surgical Mask
— Helgeson et al.
Single Study

This study notes that strenuous exercise while wearing a mask generates breathable droplets that need proper room clearance measures such as a minimum of 6 air exchanges/hr.

Last Updated: September 17, 2020
Fitness and leisure sector demonstrates safety one month after reopening in England
— UKactive
Organizational Scan Last Updated: August 24, 2020
National Study Confirms It’s Safe to Work Out at the Gym: Current Data Shows No Evidence of COVID-19 Spread in Gyms
— International Health, Racquet, and Sportsclub Association
Organizational Scan Last Updated: September 1, 2020
Disclaimer: The summaries provided are distillations of reviews that have synthesized many individual studies. As such, summarized information may not always be applicable to every context. Each piece of evidence is hyperlinked to the original source.

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