IATF COVID-19 Statement
This statement is NOT about patients that are recovering from a COVID-19 infection. The statement depends on the state-of-knowledge as per date above. Knowledge and guidelines, like the WHO guidelines1, will change in time and will be updated when necessary.
*Patients recovering from a COVID-19 infection may show a wide array of complications requiring a rehabilitation pathway which may include aquatic therapy2. Applications of aquatic therapy will be described in a future document.
The COVID-19 pandemic is a health problem affecting almost every country in the world. Restricting the pandemic and the virus spreading from one person to another is the top priority. To this end, almost all of the countries concerned adopted rules for their territory that must be observed by their population.
Aquatic therapy as one healthcare service is impacted by COVID-19. It is currently unclear whether aquatic therapy should be provided during the pandemic or suspended. Ultimately, answering this question depends on national/regional regulations to contain and control the pandemic. In those countries where skilled aquatic therapy (by health professionals) is not explicitly prohibited, and national rules for aquatic therapy are not clearly defined, the Association IATF recommends the following.
A COVID-19 triage should be performed according to the national regulations:
o If increased COVID-19 risk (based on symptoms3): no face-to-face treatment
o If no increased COVID-19 risk: face-to-face treatment can be considered.
§ face-to-face treatment can be hands-off or hands-on
• The health care professional needs to decide if face-to-face aquatic therapy is necessary to prevent irreversible decline, based on normal screening procedures, the benefit-risk balance will direct practice.
• If patients do not need hands-on treatment, national rules for social distancing should be followed in the pool and all aquatic environment areas.
• National rules count for the amount of space per person in the pool (e.g. one per 10 m2).
• If hands-on treatments are necessary, both the patient and the therapist must wear a face mask (and other protective means as indicated by national regulations).
• Caution with hands-on treatments in which faces of therapist and patient are close, e.g.
WST exercises on therapist's lap, BRRM patterns in which the therapist holds hands or arms, Aqua-T-Relax.
• If not absolutely necessary, the therapist should not be in the water with the patient at the same time. This is to increase the distance in order to refrain and to ease communication.
• Pool staff should be limited in order to reduce the amount of social / therapeutic contacts.
If possible, specific staff should be assigned to work in the pool area.
• Patients and therapists should perform a full body and hair rinse before therapy for about
60 seconds, as recommended4,5. This helps to decrease the disinfection by-products4,
which eases to maintain an adequate level of free chlorine.
• Patients who belong to groups at higher risk for severe illness from COVID-196 should be judiciously treated in an aquatic environment with careful scheduling to avoid other patients and staff.
• Also, post-COVID patients should be judiciously treated in an aquatic environment with careful scheduling to avoid other patients and staff.
• Face masks and other preventive measures utilized as per national regulations.
• Pool/poolside/changing room equipment, door handles etc. must be disinfected after each treatment.
The American Centers for Disease Control and Prevention states "there is no evidence that COVID-19 can be spread to humans through the use of pools, hot tubs or spas, or water playgrounds. Proper operation, maintenance, and disinfection (e.g., with chlorine ore bromine) of pools, hot tubs or spas, and water playgrounds should inactivate the virus that causes COVID-19", although this may take some time depending on the concentration of the disinfectant.
** CDC7 recommends a free chlorine concentration of 1 ppm (mg/L) in pools as per the
WHO8. Although chlorine and bromine inactivate the virus, swimming pool water does not sanitize aquatic equipment. Equipment disinfection needs to be done according to
existing regulations. The Queensland Government9 suggests a 1000 ppm bleach solution.
There is no evidence at this time the temperature, relative humidity and the concentration of disinfection by products above the pool - that is the area where we breathe - negatively or positively affects the activity of COVID-19. No research is currently available regarding COVID-19 survival/growth in different temperatures and relative humidity's. Evidence exists only from other coronaviruses such as SARS10. We recommend reference 11 by the Federation of European Heating, Ventilation and Air Conditioning Associations11.
Pool operators should monitor proper ventilation in the pool basin area in order to prevent development of bio-aerosols. The humid air just above water is a bio-aerosol, containing micro-organisms12, a possible source of contamination. COVID-19 is airborne and viable in an aerosol for multiple hours.
1. Coronavirus disease (COVID-19) technical guidance: infection prevention and control / WASH.. Website accessed at April 28, 2020. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical- guidance/infection-prevention-and-control
2. British Society of Rehabilitation Medicine. Rehabilitation in the wake of COVID-19 A
phoenix from the ashes. Working document, Issue 1, 27.04.2020. Downloaded at April 28,
2020 from https://www.bsrm.org.uk/publications/latest-news/post/39-COVID-19-bsrm- position-on-rehabilitation
3. Q&A on Coronaviruses (COVID-19). Website accessed at April 28, 2020 https://www.who.int/news-room/q-a-detail/q-a- coronaviruses#:~:text=The%20most%20common%20symptoms%20of,should%20seek%20 medical%20attention.
4. Keuten MGA, Schets FM. Schijven JF, Verberk JQJC, Dijk van JC. Definition and quantification of initial anthropogenic pollutant release in swimming pools. Water Research,
2012: 46, doi: 10.1016/j.watres.2012.04.012. Corrigendum WaterResearch 2014 included doi: 10.1016/j.watres.2013.12.007
5. Centers for Disease Control and Prevention. 2018 Annex to the Model Aquatic Health Code, scientific rationale. Downloaded at April 28, 2020 from https://www.cdc.gov/mahc/index.html
6. Coronovirus disease 2019 (COVID-19) Groups at higher risk for severe illness. Website accessed at April 28, 2020. https://www.cdc.gov/coronavirus/2019-ncov/need-extra- precautions/groups-at-higher-risk.html
7. Centers for Disease Control and Prevention. Website accessed at April 28, 2020. https://www.cdc.gov/coronavirus/2019-ncov/php/water.html
8. WHO (2006). Guidelines for safe recreational water environments. Volume 2, Swimming pools and similar environments. ISBN 92 4 154680 8
9. Quensland Government website, accessed at April 28, 2020. https://www.qld.gov.au/health/conditions/health-alerts/coronavirus-COVID-19/information- for/industry-and-businesses/resources-and-fact-sheets-for-industry/COVID-19-cleaning-and- disinfection-recommendations
10. Casanova LM, Jeon S, Rutala WA, Weber DJ, Sobsey MD. Effects of air temperature and relative humidity on coronavirus survival on surfaces. Applied and Environmental Microbiology, May 2010:2712-2717. doi:10.1128/AEM.02291-09
11. REHVA COVID-19 guidance document, April 3, 2020. How to operate and use buildings services in order to prevent the spread of the corona disease (COVID-19) virus (SARS-CoV-
2) in workplaces. Downloaded from https://www.rehva.eu/activities/COVID-19-guidance at
12. Angenent LT, Kelley ST, Amand St A, Pace NR, Hernendez MT. Molecular identification of potential pathogens in water and air of a hospital pool. PNAS, 2005;102:4860-4865. Doi:
Disclaimer: The Association IATF has based its statement on the best available information. IATF excludes any liability for any direct, indirect, incidental damages or any other damages that would result from, or be connected with the use of the information presented in this document.
On behalf of the Association International Aquatic Therapy Faculty