What evidence exists regarding protection and safety for playing hockey to reduce the risk of COVID-19 transmission?

Summary

The following is a short summary of the best available evidence from trusted sources that have been rated as providing high quality information on the protection and safety needed for playing hockey to reduce the risk of COVID-19 transmission. One systematic review, one rapid review, guidance from three professional organizations, one municipal guidance and one single study were found to answer this question and were used in this REAL Summary. For additional information about each of the sources, see the Table below.  For additional information about each of the sources, see the Table below.

Hockey Canada, USA Hockey (October, 2020) and Ottawa Public Health (November, 2020)emphasize that all participants in sports facilities must adhere to public health safety guidelines for COVID-19 [3,4,6]. This should include practicing physical distancing protocols that are tailored to the location, size, and type of venue, practicing good hygiene, and wearing masks when off the rink but still within the building [3,4,6]. The authors of the Return to sport for North American professional sport leagues in the context of COVID-19 (September, 2020) systematic review states that all players are encouraged to use single-use supplies when possible (e.g., towels, snacks) and should not share items such as towels, lotions, water bottles, etc. [1]. Safety and protocols for a Return to Hockey, guidance produced by Hockey Canada, notes that hockey participants must clean personal equipment including jerseys, pant shells, and socks after each practice [3]. Ottawa Public Health notes that shared equipment is allowed if cleaned and disinfected between uses within a sports organization [6]. Sports facilities must clean and disinfect areas and equipment (e.g. door handles, dressing rooms, washrooms, benches, etc.) according to health authority standards [1]. The use of closed spaces such as showers and dressing rooms will depend on provincial/territorial guidelines, but it is advised for players to dress and shower at home [2,4]. 
 
USA hockey notes in its Mitigating Risk Recommendations (October, 2020) that masks are not mandatory while individuals are on the ice, but a clear polycarbonate shield or shield and cage combination could be worn to provide more protection [4]. In the Masks for Sports (August, 2020) report, the HelpfulETH project in Zurich notes that commercially available respiratory masks were not found to be suitable for sports as they hindered the breathability and performance of athletes and that field of vision and risk of contamination when removing shields to drink were a concern with use of only face shields on the ice [2].  
 
The systematic review recommends that sports organization should designate a COVID-19 response team composed of medical staff and security to ensure appropriate guidelines will be communicated in case of any inquiries or incidences regarding COVID-19 arise [1]. Similarly, Hockey Canada recommends that hockey associations and teams should designate a communications officer who conveys any relevant information about COVID-19 and ensures that participants adhere to public health safety guidelines [3]. 
 
In the Impact of the COVID-19 virus outbreak on movement and play behaviours of Canadian children and youth: a national survey (July, 2020) it is noted that in Canada only 4.8% of children and 0.6% of youth were meeting the combined movement behaviour guidelines (e.g. walking, running and playing) during the COVID-19 pandemic [7]. Safe return to work protocols may be beneficial in promoting movement behaviour in children. The Ontario Hockey Federation outlines a general three-phase Return to Hockey Framework (July, 2020) to allow re-opening of hockey facilities while reducing the risk of COVID-19 transmission [5].  

Evidence

What‘s Trending on Social Media and Media

On October 15, 2020, a CTV News article warned that recreational hockey has the potential to become a super spreader event. The rink provides a venue that is likely well suited for transmission as an indoor environment where deep breathing occurs, and people are in close proximity to others. Some hockey leagues in Ontario have taken drastic measures to limit the spread of COVID-19 during play. Find the article here.  

Organizational Scan

As of October 13th, 2020, indoor hockey games and scrimmages are suspended in the City of Toronto as they are deemed high-risk for transmission since masks cannot be worn, and physical distancing cannot be maintained. Toronto has developed numerous programs for residents to explore within current public health guidelines. These events include ActiveTO, BigArtTO, StrollTO, ShowLoveTO, and Stay, Play and Learn at Home. [8] 
 
In June 2020, a recreational hockey game was played at an ice rink in Tampa Bay, USA. Each team had 11 players, including men aged 19-59. Five days after the game, 15 people (i.e.,14 of 22 players and a rink staff member) experienced symptoms of COVID-19. Thirteen of the 15 people who were tested had a positive test result for COVID-19. The indoor space and close contact between players during a game increases the risk of infection and creates the potential for a super spreader event. Read the article here. [9] 
 
The Ontario Hockey Federation (OHF) created a phased approach to ensure the safety of players, coaches, officials, administrators and volunteers. This plan includes information on in-person training and virtual training for athletes. In-person training will start for individual and small groups on or off ice following Ontario guidelines. Virtual training includes sports science programming such as nutrition, mental health, mental training and yoga. The OHF have also released guidelines for coaching clinics or officiating certifications. Find the plan here. [10] 

Review of Evidence

Resource	Type/Source of Evidence	Last Updated
Return to sport for North American professional sport leagues in the context of COVID-19 — John P DiFiori	Systematic Review	Maintain strict physical distancing protocols tailored to the location, size, and type of venue.   Regular testing for athletes (even asymptomatic) should be implemented.   Sport facilities must: 1) clean and disinfect according to health authorities’ standards; 2) provide alcohol stations; and 3) direct traffic with visual markers to allow physical distancing.   Single-use supplies, (e.g., towels, snacks, lotions) must not be shared.   Prohibit use of closed spaces (e.g., steam rooms and dry saunas).  Designate a COVID-19 response team (e.g., medical staff and security) to respond to COVID-19-related issues.  Last Updated: September 22, 2020
Masks for Sports — ETH Zürich	Rapid Review	Professional hockey players from the Zurich team identified essential requirements for a protective mask including respiration, moisture, sight, movement, temperature, disinfection, equipment, drinking, and communication.  The HelpfulETH project team developed a prototype for a protective mask and implemented an anesthetic mask design   Commercially available respiratory masks were not found to be suitable for sports as they hindered the breathing and performance of athletes.   Field of vision and risk of contamination when removing to drink are a concern with use of only face shields.   Last Updated: August 22, 2020
Safety and protocols for a Return to Hockey — Hockey Canada	Professional Organization	Anyone entering the facility should wear a cloth mask when physical distancing cannot be followed.   Individuals at the ice rink must always practice good hygiene, frequent handwashing and physical distancing.  Players should clean jerseys, pant shells, and socks after each practice.   Use of showers, dress rooms and storage of equipment will depend on provincial/territorial guidelines.   Hockey associations and leagues should assign one person, a communications officer, who will be responsible to ensure all updated and relevant information is shared with relevant personnel.  Last Updated: June 3, 2020
Mitigating Risk Recommendations — USA Hockey	Professional Organization	Personnel are encouraged to screen everyone entering the facility for COVID-19 symptoms.  Players should not share water bottles, towels, or any other equipment, and equipment should be cleaned/disinfected after use.  Players should consider dressing at home to avoid locker rooms and masks should be worn inside locker rooms.  Group discussions in close proximity and unnecessary contact (e.g., handshakes and hugs) should be avoided.  Teams should consider alternative programming including: 3v3 or 4v4 with smaller team rosters or using stations to maximize use of the rink.   Masks are not mandatory on the ice, but a full, clear polycarbonate shield or shield/cage combination may provide more protection.  Last Updated: October 21, 2020
Return to Hockey Framework — Ontario Hockey Federation	Professional Organization	This plan proposes a 3-phase framework for a safe return to hockey.  Phase 1: primary focus was to reintroduce the sport of hockey for the health and well-being of stakeholders in the game.  Phase 2 focuses on reintroducing hockey activities across provincial jurisdictions.  Phase 3 will involve the introduction of traditional hockey (5 on 5) in compliance with the Ontario Government Emergency Order and OHF policies.  Last Updated: July 2, 2020
Sports, Recreation and Being Active During COVID-19 — Ottawa Public Health	Municipal Guidance	Individuals participating in team sports should follow the W.I.S.E. precautions: W – Wear a mask, I – Isolate yourself from others when sick, S – Stay at least two metres from others, E – Exercise proper hand hygiene.  Individuals may join more than one league, but it is recommended that individuals limit themselves to one team/sport to decrease the risk of COVID-19 exposure.  Equipment can be shared within a sports organization as long as it is properly cleaned and disinfected between uses.  Last Updated: November 2, 2020
Impact of the COVID-19 virus outbreak on movement and play behaviours of Canadian children and youth: a national survey — Moore et al.	Single Study	This study assessed 1,472 youth (5-17 years old) across Canada.  Only 4.8% of children and 0.6% of youth were meeting combined movement behaviour guidelines during COVID-19 restrictions.  Children and youth had lower physical activity levels, less outside time, higher sedentary behaviours, and more sleep during the outbreak.  Factors associated with healthy movement behaviours: Parental encouragement and support, parental engagement in physical activity, and family dog ownership.  Last Updated: July 5, 2020
City of Toronto adjusting recreation programs in response to COVID-19 recommendations — The City of Toronto	Organizational Scan	Last Updated: October 8, 2020
An Outbreak of COVID-19 Associated with Recreational Hockey Game — Centers for Disease Control and Prevention	Organizational Scan	Last Updated: October 15, 2020
Return to Hockey Framework — Ontario Hockey Federation	Organizational Scan	Last Updated: July 2, 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.