You can go ahead and start. We've got you live. I have your audio running, and we'll just let me know if you need anything. Fantastic. That's perfect. Thank you. So, nice to meet everybody virtually, and apologies for not being there in person. I'm Dr. James Quigley. I'm an occupational health physician based in the United Kingdom and chief medical officer at HealthWorks. I'm going to be presenting to you today on the work that we did with occupational medicine and sports medicine to resume international sporting events after COVID-19. So I'm just going to pull up my slides so that you can see them. So that hopefully should have come up for you there. So let me just move through there and check that you can get those. Fantastic. So, firstly, as I've said, thank you very much for the opportunity to present and speak to you all at the American Occupational Health Conference 2022, and it's great to be here by the magic of technology that we've all become so used to over the last couple of years. As I say, apologies for not being there in person. Myself and Dr. Hussain had planned to actually be with you, but unfortunately we've had some travel hiccups, so it's just myself presenting today remotely, but thanks to the team at AOHC as well for facilitating that at very, very short notice. So as I say, I'm a UK, United Kingdom-based occupational health physician and chief medical officer at HealthWork. So we're a private OH provider that provides a number of OH services to public and private sector organizations in the United Kingdom, and traditionally we've done a lot of work with blue light services such as the police, fire and rescue, NHS-related work, and we're based in the Northwest in Manchester. And as I say, I'm here today to talk to you about the work that we did with the England and Wales Cricket Board during the pandemic. So hopefully it should be an interesting and slightly different talk, perhaps. So what I'm looking to cover with you today is just to take you a little through how the project came about, what was the design, and what do I mean when I say biosecure bubble and zoning, how we create and how we created and maintain the biosecure bubble with the event that we were working on. So looking at the components of that, such as vulnerability checks, the daily screenings that we undertook, the PCR testing, and the risk assessment of the venues. And I'm also going to pick up on some of the learning points that we picked up on, I suppose, as we went on, which like anything, I suppose, when you do something that's novel, there is a lot of learning as you go through it. And I think we would probably have addressed these things perhaps earlier on, but certainly some interesting points about advisable, the fitness for work related issues, and provision of minor first aid, et cetera, to some staff that otherwise would have difficulty accessing healthcare. So before I go on to, I suppose, the meat of the talk, it's probably useful for me perhaps to set the scene to yourselves of how we came to be involved and why we were asked to be involved by the ECB for this event. I mean, March 2020, it feels like a long, long time ago now. And it's almost surreal, casting back, casting minds back to that time. But certainly in Britain at that point, in early March, it was, of course, in other parts of the world, a very unprecedented time. And life was largely put on hold when the lockdown was announced in the middle of March. And the UK almost went onto a war footing with a lot of restrictions in terms of what you were allowed to do, what you weren't allowed to do, what could open, what couldn't be open, et cetera. And certainly, and I know I'm sure many of you in the room and listening remotely would say the same, it was a very challenging time for, well, medical services across the UK and across the world. And certainly I know overnight we had a lot of challenges from switching to a very remote way of doing things and dealing with a lot of uncertainty and different bits and pieces that we hadn't had to deal with before. And obviously, a consequence of the lockdown in the UK was a lot of sport was suspended until it was deemed safe that it could be resumed and in what manner it would be resumed. And one of the things I suppose that hit the headlines first of all was the English Premier League. So the main football league in the United Kingdom was the first event to be suspended. Now, in the background to all this going on, and again, those of you who are from the United Kingdom, either tuning in remotely or there in person, and those of you internationally that may have seen it in the press at the time, there was certainly a huge amount of concern in the United Kingdom based on what had been seen in other countries that the NHS was at risk. So the UK Health Service of being overwhelmed by the number of COVID cases coming in the door. And there were a number of pop-up hospitals set up called Nightingale Hospitals in novel settings. So they sort of commandeered and took over certain conference centres to set up extra hospital capacity. And that was the first point that we became involved, I suppose, in setting up pop-up occupational health style services. And there was a Nightingale that was based in the northwest that we were involved in during its initial set up. And we were involved, I suppose, with the challenges that arose from that, with it being in a unique and novel location, different challenges related to COVID-19, having to deal with screening of vulnerability of staff and which staff were medically safe to work in that environment, symptom screening so that they weren't bringing COVID-19 infection in and interfacing with the testing. And also, I suppose, being involved in a project where there was quite a lot of media interest. So off the back of this, we were initially contacted by the English Premier League in relation to the Premier League restart called Project Restart. And we were involved in helping them tailor their guidance and designing their vulnerability checks. So it was off the back of this and from our involvement in both of those projects that we were originally approached by the England and Wales Cricket Board following this experience and asked to assist with the plans they had for trying to return cricket in the summer of 2020. So, as you can imagine, it wasn't a, I suppose, a project without perhaps some controversy, certainly behind the scenes to begin with, because there was a lot of debate whether certainly at that time it was the right thing to be returning sport whilst there were so many other pressures going on. And it was the ECB working with their colleagues in the Department of Culture, Media and Sport that came up with the original and the initial plans for how they would go about this. And one of the concepts they came up with was running the event as a BCD or behind closed doors event. So effectively meaning that there would be no spectators like you would have at a normal sporting event. And you can see here on this slide, I've just sort of lifted exactly verbatim from the document that we were circulated for the original policy of why they felt it was important to try to resume the sport in the way that this was going to be done. And essentially, I think the agreement was, which I'm not going to go into too much detail on what it was, which I thought was a very sensible one, was that in light of all the difficulties going on in the world, if sport could be resumed safely, it would give some normality back and provide a morale boost to those who enjoy cricket and enjoy sport. But it clearly had to be done in a way that wasn't going to lead to any potential compromise to anyone's individual health or risk overwhelming the NHS, which was a big concern. Now, interestingly, when I was writing this talk, I came across some interesting images. And it's I suppose it's quite interesting how history does have a habit of repeating itself, obviously, with the pandemic and now, unfortunately, war in Europe. And I thought these pictures were rather interesting of spectators and players at sport during the Spanish flu in the start of the 20th century. And we can see on these pictures that we've got spectators on the right sitting in the crowd and also players playing with the masks. And interesting, there is evidence. And I know those sort of those who study sports history and the history of medicine deem that certainly in relation to that particular pandemic, there was a link between sporting events and transmission of the virus. And there was, again, plumbed in, I suppose, with the concern and the reason why the plan was to hold these particular events behind closed doors, because it wasn't something that obviously we wanted to happen here. So distilling the project brief into a six point plan, there were six key elements, I suppose, of the way that we were approaching this project to make it safe and viable. So the first was that the idea was to set up a model to reduce the risk of COVID-19 transmission and to preserve not just player but staff safety. And we'll come on to the exact details of how we did that later on. And this obviously had to be done in line with the latest government guidance that was available at the time. But essentially, the way that this was going to be undertaken was by undertaking a screening program of all the individuals involved to make sure that they weren't too vulnerable from a health perspective to be involved, and also to ensure that there was daily checking and screening of those individuals in the form of symptom checking, temperature checking, and also regular swab testing to make sure that they wouldn't bring infection into the bubble. Which brings me on to the third point that obviously there needed to be a high quality testing program. But again, the concern was, and certainly at the time in the United Kingdom at that point, there was a lot of pressure on testing services. So it had to be done in a way where the testing program was run externally to the NHS and didn't put any pressure on the limited testing capacity that was available there. One of the other ideas as part of this plan that we'll come on to and how that worked was looking at defined working zones for the individuals involved and restricting them to particular functional areas to reduce the number of contacts that individuals had and to reduce potential spread. And also, of course, following social distancing, which we've all been become so familiar with. And then point six, which I suppose underpinned all of the other points, was having this dedicated occupational health input and presence available to look after staff well-being at all times. So the project involved very, very close working between the ECB, the England and Wales Cricket Board, and their employed sports and exercise medicine physicians who liaise very closely with Public Health England, who obviously set the national guidance in England, and the Department for Culture and Media and Sport, which had the ultimate sign off on whether the plans could go ahead. And we then linked in very closely with them to ensure we were delivering on their six point plan to make sure that we were following it up in the appropriate way and based it on the experiences that we gained from our involvement with the Nightingale and also Project Restart. So the way that we, I suppose, originally thought of the risks that we were dealing with, we felt there were three broad categories, really. The main one being, of course, I suppose, the health risks with regards to COVID-19. So there was clearly a lot of concern at that time about potential risk to players and the support staff for players, whether that was the actual sporting support staff, but also including those who worked in the hotels, the security, et cetera, et cetera. And the risk of any of those becoming severely unwell from COVID-19, or even worse, obviously, suffering a death. And that was obviously something that if there was felt to be too big a risk of something like that occurring, we wouldn't have been able to proceed with the project. There was also, as I've mentioned at the time in the country, a large concern about the NHS being overwhelmed. So there was certainly a particular debate about whether it was appropriate to go ahead with an event such as this. And there was concern and certainly a lot of thought given to the fact that it was important that the NHS didn't become overwhelmed. And it wouldn't have been acceptable, for example, to rely on the NHS to undertake the testing, or if there was multiple hospital admissions resulting because of transmission that was occurring because of these events. So that was another thing that we had to factor in. And finally, and also importantly, was the reputational risk. Clearly, this is obviously a very high profile event. There was a lot of media interest and media speculation about it with a number of very high profile individuals involved. And there was a risk that we not proceeded very carefully, and we got things wrong. There was a potential reputational risk to the ECB as well. So that had to be very, very carefully managed. And of course, as well, like all of these settings, and as we'll come on to, there was perhaps some difficult conversations that had to be had in terms of screening individuals about whether they were felt to be too high risk to be involved. And obviously, with some of the individuals that were very high profile, that can also be a difficult conversation. So there were lots of perhaps unusual and slightly different things that had to be dealt with in this situation. But the experience that we'd had from the football with Project Restart, and as I said, the other Nightingale stuff was certainly useful. So the first thing that had to be decided on really was which venues were going to be used to conduct these events and have the actual matches played. Now, this was a bit of a challenge, and it wasn't without controversy, because as you can imagine, at the time, the suspension of all the sport meant that the venues for a lot of these sites were desperate for revenue and wanted to be involved. But there was actually only two initial venues that were felt to be appropriate to proceed with this to play the games. And one of the big reasons for that was the provision for accommodation, either actually on site or very close by. So the two venues that were identified, some of you in the audience may have been to them or certainly I'm sure will have watched matches on them at television. Both of them are very famous. We've got the Old Trafford Cricket Ground in Manchester itself, which is not too far from where I'm speaking from, and also a GS ball down in Southampton. Now, for those of you who've perhaps not been to those grounds, they're in quite different locations. I mean, Old Trafford itself is actually in Manchester, within the suburbs, it's in the inner city suburbs, it's not too far from the city centre, whereas a GS ball is a little bit further out and a bit more isolated. Now, as I say, it was controversial at the time, which grounds were going to be picked. But for the reasons that I've mentioned, the on-site accommodation for staff and not just the players, but the actual other support staff, such as the media, was the reasons why those were picked. It was easier, as I say, to actually form a bubble at a GS ball with it being more secluded, because you could almost cut it off and seal the road off from the general public and make sure whoever was entering the site, you were very clear who they were, where it was a bit more difficult, Old Trafford. And in particular, one of the difficulties that during the middle of the project that we highlighted was, due to a couple of different reasons, we eventually ended up with not enough accommodation for all of the media and some of the staff that weren't on the inner zone of the bubble, which presented a challenge, because obviously there was a risk there that they may bring in COVID-19 and infection from the outside world. So one of the things that we had to actually come up with Old Trafford during the middle of this project was another venue for accommodation for some of those individuals to stay nearby to the ground, where there were still restrictions and control measures in place, with a kind of land bridge, if you like, of how they made their way to the actual site at Old Trafford. So we had to impose on those individuals strict rules on social distancing when they were walking or travelling to the site, making sure that they were clear that they shouldn't be going into any shops or mixing with any members of the public. They should ideally be travelling between the site at quieter times, not using public transport, etc. So there were challenges that certainly developed during the project as we went through. Now, the fixture list itself, as you can see here, was actually quite packed. So this was the original fixture list for summer 2020 that had been redesigned when the pandemic hit to allow some cricket to be played. And you can see there that there's a lot of careful coordination that had to be allowed to allow the players and staff and support staff to arrive and be available to undertake isolation and training prior to the matches taking place. And there was obviously a lot of pressure, I guess, in that way to make sure that we didn't have any situations where COVID-19 developed in the bubble, because it clearly would have led to a lot of compromise to this schedule and caused a lot of disruption. And in particular, you'll recognise, I'm sure, the abbreviations on that slide for the different teams, such as the West Indies, Ireland and Pakistan. For those international teams at that time, the COVID rates in those countries were actually lower than the UK. So there was a lot of concern, particularly on their side, about them actually travelling into an environment where there was more COVID-19 than there were in their host country. So there was a lot of work that needed to be done to reassure them that this schedule had been thought through, that it wasn't rushed, that appropriate control measures were in place. And this brings me, I guess, on to the next slide, really, which was the other part of the work that was being done, not just at site, but in preparation for these games. So there was very close working undertaken by the ECB teams, with the overseas authorities for the relevant teams that were travelling, including their sports and exercise medicine physicians linking in with us, to really reassure them and inform them of the detailed risk control measures and protocols that we put in place, and the hard work that we'd done before the matches were even played. And as I say, there had to be a lot of close liaison to reassure them that we had thought through every eventuality and to reassure them that they would be safe coming over. Another factor, of course, was before they came over, we wanted to make sure that there was no individuals that were particularly vulnerable that we didn't feel were traveling. So we'll come on to exactly how we did that on the next few slides, but all of these individuals actually had vulnerability screening even before they set off on the plane to travel over to us. And we conducted that remotely before they traveled. They all also had a pre-departure PCR testing. So they all had to have a negative PCR before they tested for anyone that was coming with them, the whole team, any support staff, and any family that were traveling. And again, there were, as I said before, some unexpected, interesting situations that developed because we did have individuals that had had COVID-19 and subsequently then recovered, but were still testing positive on their PCR tests. So they were detecting old virus, if you like. And we did have to seek some virology support and look at the cycle threshold CT counts of some of the testing, and then make an OH decision on whether they were considered fit to travel. So for example, if they had a low CT count, that's obviously an indicator of more viral material and a suggestion that they are infective and are still in the acute phase of the disease. Whereas if they've got a high CT count, that's usually indicative of less viral material. Though on its own, it's not always useful because it can be a sign that they're perhaps in the early stages of the infection. So often these individuals who did have a positive test would then have serial PCR testing, and then a decision would be made if they had a rising CT count that it was felt they were less likely to be infected and we might be happy with them traveling. And the travel, of course, in itself did present difficulties as well. And we had to draw up an entire protocol in related to that, because the concern was for individuals that were traveling, the staff and the players, that they might contract COVID-19 on the trip over. So we had to plan things about the cleaning schedule, for example, of any team buses, team coaches that they were using, individuals where they could, for example, if they were based in the UK and they were traveling between venues, they were encouraged to travel in their own vehicle if possible. Where we had other support staff taking them, the drivers had to go through vulnerability checks and PCR testing as well, like anyone else involved in the project. And the players were supposed to be transported directly from isolation to the ground, et cetera, to make sure that there was no potential contamination brought into the bubble. So before the events even took place, we undertook working to a very, very tight schedule, a very detailed risk assessment and site visit at each of the venues. So in particular, focusing, of course, on Old Trafford and Aegeus Ball, there were some other ancillary sites that were used, such as Worcester and Derby, purely for training and isolation purposes for the teams when they arrived because of the tight schedule, they couldn't always arrive directly at Aegeus Ball or Old Trafford. And we assessed and risk assessed all of those site venues. So in particular, we looked at things like the building and control environments, so the entry and exit protocols that had been drawn up, how the vulnerability checks were going to be conducted, how we were going to ensure that those had been carried out on each individual, how the daily symptom check was being carried out and how the gatekeeper system was going to work. We also made sure that the individuals had had an education programme on COVID-19 risks and everyone, again, regardless of sort of their rank or their status, if you like, had to complete that and agree to abide by the rules within the bubble. We also looked at ensuring that there were COVID-19 risk mitigation officers on site. So each site had a dedicated health and safety personnel and health and safety officer that took responsibility for that. We also inspected and looked at how they'd undertaken the zoning and the functional areas on the sites to make sure that there was no unnecessary mixing on the sites beyond what was necessary. Looking also at the signage, for example, on site to make sure that was clear around social distancing and where people should and shouldn't be entering, making sure that, for example, to support the zoning systems, people had the correct accreditation so that they couldn't move between zones if they weren't allowed to do so. And also making sure that there was appropriate access to the correct PPE. So for example, with masks, hand sanitizers placed in the right place. And there was actually a very clever system, as it says on here on this slide, that they came up with with the cleaning system as well, where we use this thing called a red dot system, where when we walked around, we went around the health and safety staff, occupational health and the cleaning staff and identified areas that had a very high throughput of individuals or were deemed to be likely touch points and regular contact points. And the very simple way that we mitigated this was we put a red dot, a red sort of pen or a red marker above whatever point that was, which highlighted to the cleaning staff on site that that was a particular area for focus. And for those particular sites, like those handles for common exit and entry points, the cleaning staff would often be cleaning those several times an hour, wiping them down to make sure that they weren't a potential area where infection could be contracted from. There was also a lot of work done from the health and safety perspective on risk assessing the HVAC stuff that was in place and maximum occupancy risk assessments to make sure there was adequate ventilation. And it even went down to the detail of a laundry schedule. So the players and the playing staff were encouraged to do their own laundry where possible and where for whatever reason that wasn't possible, we had to have a dedicated protocol, again, for contractors that would deliver or come onto site to perhaps take the laundry off and clean it and return it for how that would be handled. So again, they would go through the vulnerability questionnaire, the daily questionnaire, et cetera, and anything that they brought back on site would be wiped down and sterilized from the packets that it was brought back in before it was actually taken into the bubble. So in short, what we did is produced a very detailed report on all of these particular factors that then went back to the ECB for sign-off. And obviously, I have not provided a copy of the full report here today. That wouldn't be possible in too long, but this perhaps gives you a bit of a flavor on this slide about how we went through each individual area. We provided detailed comments and gave a RAG rating for where we felt that was up to and any measures which we felt needed to be improved upon. And I have to say, actually, the work that was done by the ECB, the DCMS, on their initial protocols, even before we got involved, was very, very detailed and was a fantastic basis. And actually, in a lot of cases, the work that they'd done on the sites, apart from maybe tinkering with it a little bit and altering it very slightly, was already in place and had very, very detailed measures. So I just wanted to speak to you a little bit now about the zoning that we mentioned before. So the very simple context of the zoning, I guess, if you like, and the aim of it with the zones and the functional areas was to minimize the interaction as far as possible between individuals to reduce the risk of COVID-19. So very simply trying to make sure that individuals, if they didn't need to be in an area or they didn't need to mix with certain individuals, for example, the players, that they would then not be ever entering the zone where they were. So it just breaking those individuals into functional groups, it did mean if we unfortunately did have a breakout, we would hopefully be able to contain it and not have it spread onwards and minimize any potential disruption to the bubble. If that did indeed occur, though obviously the idea was to prevent any infection even getting into the bubble, but we did have that second line of defense, if you like, to try and prevent any onward spread if that did unfortunately happen. So the biosecure environment itself was actually divided into three main zones that were then subdivided into functional areas. So the first zone was the PMOA zone or the player and match officials area and the field of play FOP. Zone two was the inner zone of the stadium and zone three was the outer zone of the stadium. And each of those zones was protected by security who would check individuals accreditation and make sure that they have the correct accreditation for when they were going in. And if they didn't, they would be challenged to ask why they were transiting between the zones and they had to have an adequate and reasonable reason to do so. And then within those zones, furthermore, the staff were divided into actual functional areas. So you had staff working in very, very small groups. So again, the idea being to minimize any unnecessary interaction. Obviously, as we mentioned, unfortunately that was a little bit more tricky, for example, at Old Trafford because of the limited accommodation on site. And we did have individuals that were perhaps coming into the outer zone, so zone three, or on some occasions, even going into zone two, the inner zone of the stadium that potentially weren't on site in the bubble for the whole amount of time. And that did need some extra thought, as we mentioned about this land bridge and extra mitigation measures and just really highlighting to those individuals to take care not to unwittingly transfer infection into the bubble. So in order to enter the actual biosecure bubble, biosecure environment, individuals needed four things to do so. So the first thing was the recreditation pass. So this was, as I've said, the document that allowed you to go into the area that you were designated to be in. So one of those three zones, and then your functional area. And in order to actually get into the ground, that was the first point of challenge, if you like. You had to produce that and show that you had an appropriate reason, not only to be on site, but that you knew actually where you were going and that you understood that you shouldn't go between zones. So that was the first thing that was needed. And then on the occupational health passport itself, which as we progressed into the summer, became a little bit more sophisticated. Once the software caught up, we actually had an OH passport that allowed people to passport entry into the biosecure bubble. And this consisted of three constituent parts that plumbed into the accreditation. So first of all, we had the vulnerability check, which I'll come onto on the next slide. And this was done once. This was the health screening questionnaire to make sure an individual wasn't vulnerable from a health perspective and was deemed okay to be on site. They also had to have a valid PCR test done within the agreed timeframe. And then there was a daily symptom questionnaire and thermal scan. And provided all of these four bits and pieces were in place, the individual was then granted entry to the ground. And there were absolutely no exceptions to this. This applied to everybody from playing staff, very sort of senior, high profile, experienced individuals, the staff on the ground, the support staff. It was a complete blanket approach, this. So the vulnerability questionnaire was the screening questionnaire that we used to detect health issues that may predispose to a risk of severe COVID-19 infection. So for example, leading to hospitalization or death. And what we did was we ensured that every member of staff that was involved in the project that was gonna be on site, even if that was for only one day or even a matter of hours, we did have, for example, on one day, some contractors that needed to come in and fix something related to the air conditioning and also the lifts. And they were actually only on site for a couple of hours and the work was deemed essential to go ahead. They still had to go through this process and have all of these bits and pieces, even though they were only actually present for a few hours. And this questionnaire then was assessed by a qualified member of the OH team. So either an occupational health nurse or an occupational health physician. And depending on what they filled in, it was sometimes possible to pass these individuals on a paper screen alone. More often than not, we did need to ring them where they declared a health problem to elucidate some further information. And they were classified very simply on a red, amber, green style approach. So as green, yellow, or red, denoting their risk. And the high risk individuals were excluded from participation, which as I say, was a difficult one because you obviously had a lot of people from across the spectrum that were desperate to be involved. It was a very difficult time. People didn't really want to be sitting at home unnecessarily, and they were very keen to be involved in what was a novel project. But there were some individuals that for one reason or another, we just felt were too high risk, unfortunately, to involve, and we did exclude them. This was completed only once, unless the person's health circumstances changed whilst they were on site. And as I say, there were no exceptions to this. So every member of staff, including our staff, had to go through this process, including members from the media, et cetera, et cetera. And it was actually seen as a very positive and felt to be a very positive thing. Certainly our staff received a lot of very positive feedback from anyone that went through this process that they felt very supported and they felt very cared for. I think a lot of people at that time did feel very vulnerable from COVID-19 because it was such a novel situation and a novel disease. And certainly I know all the staff that we dealt with felt very helped by having the availability of this. And as I say, it was also very egalitarian that everyone had to go through this process and the support was equal to all. So the questionnaire that we actually sent out, hopefully you can see this on your slide in the room or on your screen, because I appreciate there's quite a bit of text there, was a very broad screening questionnaire. We sat down and designed this based on the questionnaires that we'd looked at for Project Restart and some of the work that we'd done for the NHS Northwest Nightingale as well, looking at particular known risk factors at the time for severe COVID. So you can see the type of things that we were looking at were age, underlying medical conditions, BMI, looking at, for example, because we appreciate sometimes individuals don't always declare everything if they think if they're on medication that the condition perhaps isn't relevant. So we asked in relation to that. And we also asked about whether there was anything relevant that the person had been informed by their GP. And we took into account some perhaps other risk factors that we felt might necessitate us ringing the individual to give them some extra advice. So for example, if they were commuting to work on public transport, for example, for some of the staff that were in the outer bubble who were working in the hotel, we would usually call them and give them some extra advice on minimizing COVID risk. And the way that we came to a determination on their status of green, amber or red, we used really a combination of clinical acumen to do that. And then also, I'm sure many of you on this call will probably have come across the Alima COVID age tool, which was designed to stratify risk with regards to COVID-19. And we helped that inform our thinking, but ultimately the decision was a clinical one taken by the OH nurse or the OH physician assessing the individual. And as I've said, because of the risks of the project and wanting to make sure that the project proceeded safely and not putting anyone at risk, we had actually quite a low threshold for excluding individuals. And this did lead to, unfortunately, I was having to say to some individuals that we felt they were too high risk for them to be involved in the project. And of course these conversations, they are difficult, but I have to say everyone that certainly we spoke to did understand and understood the reasoning behind it. And as much as they wanted to be involved, they did appreciate that the reason that we'd taken the decision was that we felt that at that time that the risk was too high. So in terms of provision of the regular PCR testing, this was again undertaken on everyone without exception. In the initial period when we first started, every individual had to have a swab done every seven to 10 days. It was a nasopharyngeal swab, and it was mandatory, as I say, for all staff. And anyone who was out of ticket wasn't allowed on site, you had to have a confirmed negative within that site. And there were really some challenges with this that I guess we perhaps hadn't fully appreciated at the time, in particular with members of the media who on the schedule we were working to, if you cast your mind back to the slides that I showed earlier, they weren't necessarily working just on our project. So it wasn't uncommon for them to, for example, be present to cover the cricket, and then they might move on to cover the football or go abroad to cover the Grand Prix. And this made it actually very difficult for them sometimes to stay in ticket. And we had obviously PCRs posted out to them on occasion or try to be as flexible as possible in ensuring that they could get access to PCR. But certainly the peripatetic nature of those staff made that a challenge to make sure that the right people always remained in ticket and had the correct PCR done so that they could enter site. And then the daily questionnaire and thermal checks. This was the component that I mentioned before that was the daily check. So the symptom check was a self-reported screening questionnaire. Again, this was in the stages when we had the app available actually reported by an app. So the individual would fill that in every morning. They were prompted to do it and they would declare that they had no symptoms of COVID-19. And again, their accreditation wouldn't activate for that day until they completed that. When they turned up at site that morning, they then went through the thermal scanner to check that their temperature wasn't raised and provided their symptom questionnaire was okay and the thermal scan was okay. They were then guided through and allowed to carry on. Now, as I said before, similar to the initial vulnerability check on everyone, we had a very low threshold to exclude individuals from site. So any individual that reported any symptoms, they weren't allowed entry to site until they'd spoken to an occupational health nurse or occupational health physician. We take a detailed history from them going through their symptoms and try to work out what was going on. And certainly from our experience, this was where the clinical acumen side of things was really, really important. And we did have one or two cases at both sites where we actually prevented an individual either at the gate or before they arrived at the gate from attending the site that subsequently tested positive for COVID-19. So that was a really, really important method of preventing COVID-19 from getting into the bubble. We did as well, I mean, as I say, have a very low threshold for excluding individuals. So in many cases, we did adopt a sort of cautious approach and a safety first approach. So where we had individuals with any symptoms that we were even slightly worried about, we took the view that we would rather exclude them, even if in some cases they were PCR COVID-19 negative, because we wanted to protect that bubble. And in most cases where we excluded someone where they had symptoms, we would usually mean that they were out for the 10 day period. And we would usually want them to have a negative PCR before coming back to site. Interestingly as well, another sort of point, I suppose, that came up in relation to the work that we were doing when we were on site was some issues with the thermal testing and the thermal scanners. So the thermal scanners that we were using in most cases, we did have handheld ones like demonstrated on this slide, but there were also a larger one that was in a tent because it was a bit easier to just have individuals walk through. Unusually for the UK, we actually had some very nice weather down in Southampton, which was very hot. And on one of those days where the tent was, where individuals would walk through, which I'll show you on one of the later slides, the sunlight heated that up. And unfortunately, we had a period in a couple of hours in the afternoon where everyone that went through was reading a core temperature of about 45 degrees, which thankfully we were able to highlight wasn't accurate, but it did lead to some challenges. Interestingly, in Manchester, which in typical fashion is usually cold and wet and windy, we did have some mornings, even in the summer, where individuals who were driving to site very early in the morning when it was cold turned up in their car where they'd have the heaters on their car blowing onto them. And again, when they got out of the car, they were reading hot on the thermal scan. So we had to take a bit of a pragmatic approach at that, give them some time to perhaps walk around and then go through the scanner again and take a decision on whether we were happy for them to enter. So there were all these little, I suppose, hiccups and problems, which was why it was essential to have that OH medical input on site to take the decisions about how to manage those cases. As I mentioned on the start as well, in the initial aims, we did have some case management aspects and first aid as well. So any individual that did have COVID-19, we case managed that until their return or they exited from the project if they weren't coming back. So we would ring them daily from a welfare checkpoint of view, make sure that we were signposting them to access emergency care via the NHS if they did need it. We made sure that we were making the decision making on the return. So no one was allowed to return to site if they were off with COVID-19 until they'd had OH clearance. And in many cases, as I said, we did direct them to have a negative PCR or we would look at their CT count. So we took very much control over that and made sure we had control over that process to ensure individuals didn't enter that we were concerned about. We did also provide some very basic first aid to those in the bubble that weren't able to easily leave. As I've mentioned already, unfortunately, we did have individuals that were very peripatetic. So they didn't easily have access to their general practitioner, as is the system in the UK where you register with your general practitioner. And we did have some individuals that we needed to treat for very minor ailments. So cellulitis, pressure sores from the mask. We had some toothache and cut scrapes and bruises and interestingly, quite a bit of mental health related anxiety from being in the bubble, being away from family, etc., etc. And as I say, our onsite presence was was universally popular. And I think certainly what was appreciated was a lot of staff that perhaps wouldn't usually have had occupational health support. We were dealing with a lot of individuals such as cleaners and hotel workers that traditionally wouldn't have access to that OH support. They felt very reassured and found it very helpful to have that OH support that they could access any day if they needed to and that medical support. Now, there were some hiccups during the planning, as with all of these things and some spanners in the works. So as we were going through, there was obviously a lot of political debate in the background about the wider reopening of the UK and when other aspects of normality were going to return. And you can see here on this slide, there was some stuff that got into the press actually around the start of the project about whether the cricket ball itself was a natural vector for disease. And there was a comment made by the prime minister at a press conference in relation to that, which caused some concern. The comments that he was making were actually in relation to the return of county cricket, which we were involved in as well, which is the cricket where professional players play for their county. But there's a little bit less funding there. It's a bit more tricky to run a biosecure environment because there wasn't the funding available. But clearly, the remarks that were made at that press conference did potentially have an impact on this project. And thankfully, there was some clarification that was then issued a week later that it was OK to go ahead. But again, it's a very good example of perhaps what I mentioned before about the media aspect and the reputational aspect of managing a project like this and slightly different perhaps to other work that we would traditionally be involved in. So I'd like to just perhaps show you some pictures now to contextualise some of the points that I've made and hopefully give you a little bit of a feel of what it was actually like to be on the ground at these events. So I've got some nice pictures that I took when I was on the early morning shift at Old Trafford. So this was taken about, I think, half five in the morning. So I had a very early start that morning and I was manning the gate and being the occupational health physician on the ground for any problems. And you can see on that slide how we had a one way system. So every individual could only come in one entrance to site, whether that was a contractor, a player, et cetera, et cetera. And they all had to go through the same checks. So just to put this on a schematic for you. If you imagine this one way system, essentially everyone had to come through and first of all, show their accreditation and their accreditation was only valid if they'd had an in-date PCR result as well that was negative. They then came to the next gate and showed that they completed their vulnerability screen. And that was scanned in my QR code and also that they've done their daily symptom check and that was OK. And then they proceeded to the thermal scanner and provided that was OK, they were then allowed entry into the site. And then on this site, this is a picture I took at Aegeus Ball on a lovely sunny day. You can see there on the cart, we had Ella, the venue medical manager. So these guys were the link on the ground from the ECB that were responsible for coordinating all medical aspects within the bubble and linking in with the ECB doctors and our medical staff. And they were responsible as well for ensuring that the right people were in the right zones when they needed to be. And I think Ella here, she was transporting PPE supplies around site because you can imagine we went through a huge number of masks and gloves, etc. So there was a lot of stuff to be moved about. And this picture is perhaps a better representation of the one way system. So this is Aegeus Ball. If you can see on the right hand side of your slide there, that's the entrance on the far right that you would drive up to. And the first tent that the individuals would come to would be the screening tent where they proved that they filled in their questionnaire. And these also doubled as the sites for PCR testing when those testing days were running. We then had the medical rooms that were available for the OH physician and OH nurses to sit in and be present on site if they were called for support. And then you can see on that other picture, the temperature sort of tent at the end. And you can see it's sort of quite exposed there. And on the sunny day, unfortunately, got a lot of sun. And we did have those other rooms as well. There's COVID isolation rooms, which thankfully we didn't actually need to use if we did have someone that turned up acutely unwell. But what we aimed to do was actually prevent them ever from getting to site. So the strong message that we put out was if you do have symptoms, please don't turn up to site. Contact your manager and they will then put you in touch with occupational health. And then just a couple of other pictures here. You can see, again, security at the gate there. So, as I said, Aegeus Ball was quite easy for this because it was so secluded. It was very easy to strictly control who came on site and make sure they have the correct accreditation. And then we had lots of signage and hand sanitization points as well. And then internally, we had very clear social distancing. So you can see the dividers. This is where I went to eat my dinner every night when I was staying on site for the week. And in particular, these were rooms that we selected because they were large, they were well-ventilated. And hopefully on the slide there, it's clear to you. You can see the clear one-way system and the markings about staying two meters apart, etc. So the result then was that we managed successfully to bring the first international sporting event back post-COVID. And you can see that I was very lucky to have a ringside seat when that happened at Aegeus Ball when England played West Indies. And you can note that in the ground there, I think I'm the only person sat watching it. And it was a very, very surreal experience to watch an international sporting event like that played with no spectators at all. And it was very, very quiet and very, very different to any sporting event I've ever been at before. So at Stumps then, by the time we came to the end of this project, thankfully, we'd achieved returning cricket post-COVID-19. We'd had the first international sporting event post-COVID-19. In the end, we processed over 3,000 vulnerability questionnaires over the course of the summer. And we had over 100 direct patient contacts on site. We also, I'm pleased to say, had no COVID-19 cases that got into the COVID secure, biosecure bubble. As I said to you before, we turned away the ones that potentially were the risk for that. There were no fixtures that needed to be cancelled. And I'm also extremely pleased to say that there was no one that was hospitalised or became severely unwell, and no deaths attributable to the project. So all in all, a very successful project. So I suppose the learning points and the takeaways that I wanted to give to you from this talk today. Firstly, I suppose even with novel diseases like COVID-19, the sound principles of occupational medicine apply. And I think we applied them with great success here, such as risk assessment, using the hierarchy of controls and giving very clear and unequivocal guidance and advice to management. I think probably the other key to this project was having a small and cohesive clinical and non-clinical team that communicated very closely, worked very closely to project manager and ensure that it was implemented, planned and delivered successfully. We also had to use some ingenuity and use some different concepts that we were less comfortable with. So to begin with, when we first started, unfortunately, there were some teething problems with the app. So to begin with, the way that the symptom questionnaire was delivered, we actually set up an HTML link that came to an inbox. And if you reported a symptom, it flanked you with a code and directed that to us in our inbox. But it was a bit more manual than the system we eventually came up to and came up with. But it worked effectively and kept COVID out. I think also it's a sort of a brilliant challenge, COVID-19 for OH medicine in terms of putting it as a forefront and front and centre of the specialty. And hopefully raises the specialty and will attract more clinicians into the specialty. Certainly, I know the conversations I've had with colleagues in general practice in the UK and other hospital specialties, when I've told them about this event that we've been involved in, they've been tremendously interested in it. And I'm hoping to poach some of them across to occupational medicine in due course. And I suppose the fifth and final point and one that I want to pose to you all today is the support of the support staff. I think probably one of the things that certainly came through very strongly to us was that individuals who support the players really, really do need that support as well themselves from an occupational health perspective. And if you have those support staff that become ill, like your chef or the individual that does the laundry, that can impact on team performance. And I think in this project, we demonstrated that looking after everyone well was received very positively. And an egalitarian approach like that is very, very important. I'm just aware of time. So coming on to the last couple of slides and then very happy to take questions. So I just wanted to say as well, just to give full credit to my colleagues that were involved in this project. Obviously, I've got the privilege of presenting to you all today about this, but it certainly wasn't all down to me. You know, I work very closely in the MDT with clinical and non-clinical colleagues across the OH and SEM disciplines. And it was a huge team effort and it certainly wouldn't have worked without a lot of dedicated hard work from people going above and beyond to deliver it. And I think also an important word to the cricketers and the playing staff themselves who enjoyed very, sorry, who endured very long periods of isolation, cut off from the outside world. And in particular for West Indies and Pakistan, travelled to the UK when cases were higher. And I know that was a particular concern at the time. So full credit to them. So the final thing I wanted to say before I conclude today, and hopefully it's been an interesting talk for you all and perhaps a little bit different, was another thing I learned writing this talk was actually the first international cricket match was played by the USA, which I certainly didn't realise. So it's quite appropriate that I suppose I've delivered this talk at the AOHC today. But in summary, it was a fantastic project to be involved in. It was hugely worthwhile and very rewarding. And to borrow a phrase that I came across during the pandemic itself, which I think sums up this project, whilst life depends on science, I think it's the arts, the humanities and sports that make it worth living. And it was fantastic, I think, to play a role in allowing those things to return during COVID. And I think this particular quote that I came across sums up very nicely the fantastic nature of cricket and why it's such a fantastic sport. And certainly it was a great privilege to be involved in this project. So thank you very much for listening. And I'm very happy to take questions now and also connect with anyone after the talk. As I say, apologies for not being there in person and being able to talk to you in person. But I'm very happy to take anything through the app now. I'll just try and get that up. I'm bringing the microphone live now. Anybody have any questions? Looks like we're clear on this side. Fantastic. Sorry, I can't seem to get into the Swapcard app. So I'm just trying to log in to see if I can. I don't know if anyone's posted anything on there. I'll just double check. Yes, sorry, there's some questions about a handout, I think. What I will do is try and get some course of handout over to you. Unfortunately, I wasn't able to do so because of the pictures. The slide was too large. But what I will do is liaise with Heather and see if I can get something over to you. And I think there's a couple of other questions. Did this occur before the event? Yes, it did. And if not, were there any practices pulled from that experience to inform the execution of these BCD events? That's a good question, actually. I'm not too sure. I can see someone, I think, has answered that, John. It looks like they both started at the end of July. I'm not 100% sure about which one was first. Actually, I think certainly we thought this was the first one. But I'm not 100% sure. I'm not 100% sure. Well, thank you for your time today. Is there anything else that you'd like to discuss before we wrap up? No, that's everything from me. Thank you very much for everyone's time. And I'm going to wrap up now. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. And hopefully have a brilliant conference. And I hope to be at the next one, travel circumstances permitting. We'll take care in the meantime. Thank you very much. Thank you. Thank you.

Dr. James Quigley

occupational health physician

chief medical officer

HealthWorks

occupational medicine

sports medicine

biosecure bubble

COVID-19

PCR testing