Société Belge de Médecine Hyperbare et Subaquatique asbl
Belgische Vereniging voor Overdruk- en OnderwaterGeneeskunde vzw
Position of the Belgian Society for Diving and Hyperbaric Medicine(SBMHS-BVOOG) onDiving after COVID-19 pulmonary infection
April 12th, 2020
The COVID-19 pandemic has had a major impact on recreational and professional diving
activities, with an almost complete cessation of this activity during many weeks/months.
These measures were a logical consequence of Government and Public Health Care
recommendations to limit unnecessary commuting but also because it is virtually impossible
to observe the regulations of “social distancing” and avoiding the possible sharing of divers’
breathing equipment. Lastly, there is a real possibility that emergency first aid teams may beoverwhelmed by cases related to COVID-19 or the logistics involved (decontaminationprocedures), and not be able to respond in a timely and efficient manner.
When the precautionary measures to combat the pandemic will be relaxed, it is important toresume normal recreational and professional diving activities as soon as reasonably possible,
both for the social, physical and mental welfare of the diving population. The question has
been raised, whether having suffered and recovered from COVID-19 has any influence on themedical fitness to dive or the risk of diving accidents.
Novel Corona Virus (SARS-CoV-2) infection (COVID-19) can manifest itself with various clinicalsyndromes, ranging from no symptoms, over a flu-like syndrome, to severe pulmonary
compromise (ARDS – Acute Respiratory Distress Syndrome) and cardiac symptoms(cardiomyopathy). Factors that determine the severity of COVID-19 symptoms are butincompletely known: older persons, suffering from other medical conditions, are an obvious
group at risk; also, heavy smokers and obese persons seem to have more risk ofcomplications; however, there are numerous cases reported of young, previously healthy
persons in whom the disease has had a sudden and dramatic evolution. In general, if thesymptoms were mild and improve within a week to complete resolution, the risk forpermanent damage to heart or lungs is very low.
The Board of the SBMHS-BVOOG, after examining the relevant and available literature anddiscussion with several experts, recommends:
1. Risk of spreading COVID-19: a person who has had symptomatic COVID-19 can, just as
someone who was infected but did not have symptoms, spread viral particles in nasal ororal secretions for a certain period after recovery, and thus, still be contagious to others.
The exact period during which this is possible is not known and probably variable, but has
been reported to be up to 37 days or longer. This is an important consideration for thepossible sharing of breathing regulators (buddy-breathing) but also for rescue actions incase of a diving accident.
Secretaria(a)t: Sigrid Theunissen – Weygenstraat, 26 - 3060 Bertem
Tel: 0476/44.10.44 – E-mail: secretary@sbmhs-bvoog.be
Website: www.sbmhs-bvoog.be – N° Enterprise: 428.739.109

Therefore, it is recommended:a. That divers who have had symptomatic COVID-19, wait a minimum of TWO months,
preferable three, before resuming their diving activity.
b. That divers who have tested positive for COVID-19 but have remained completelyasymptomatic, wait ONE month before resuming diving.
c. Divers who have never had symptoms and have not been tested (who either have notbeen infected or have had the infection completely asymptomatic) may not havedeveloped immunity against the disease (currently, serological tests are not widely
available and do not confirm with 100% certainty a sufficient level of immunity).
Therefore, they may still be infected by other divers and would need to observe awaiting period after the release of the confinement period. The duration of this waiting
period may be variable depending on the local situation (type of diving, location andlocal organisation).
d. Divers and dive centres should observe strictly the guidelines for disinfection of divinggear (as issued by the diving Federations and DAN Europe).
2. Risk for pulmonary overpressure syndrome (lung barotrauma): a person who has had
COVID-19 infection with severe pulmonary symptoms may suffer from prolonged or evenpermanent pulmonary damage, even if the lung function seems to have returned to (near)normal. This damage may give a higher risk for lung barotrauma, even after dives without arapid or uncontrolled ascent.
Therefore, it is recommended that a diver who has been hospitalised with or because ofpulmonary symptoms in relation to COVID-19, should, after the three-month waiting period(as indicated above), undergo complete pulmonary function testing as well as a highresolution CT scanning of the lungs.
Pulmonary function testing should include FVC, FEV1, PEF25-50-75, RV and FEV1/FVC), andthe CT scan should show a return to normal, before resuming diving. It is important thatthese tests should be interpreted and validated by a medical officer with specificknowledge of diving medicine.
If major pulmonary symptoms have been present, even if not requiring hospitalisation,
pulmonary damage may have occurred and a pulmonary function testing and CT-scan areuseful tests.
3. Risk for cardiac events: in the context of general illness and severe pulmonary infection, aCOVID-19 cardiomyopathy may not a prominent symptom and may even go unnoticed
during the acute phase of the disease. This however may be the cause of heart muscle
damage and subsequent scarring. Cardiomyopathy or cardiac scar tissue may be an
important factor in the occurrence of sudden cardiac failure and sudden death during
diving immersion.
Therefore, it is recommended that a diver who has been hospitalised with or because of
cardiac or pulmonary symptoms in relation to COVID-19, should, after the three-month
waiting period (as indicated above), undergo cardiac evaluation with echocardiography andexercise test (exercise electrocardiography) to ascertain normal cardiac function.
If major pulmonary symptoms or extreme fatigue/exhaustion have been present, even if
not requiring hospitalisation, this may indicate a possible cardiomyopathy and cardiac
testing is useful.
Secretaria(a)t: Sigrid Theunissen – Weygenstraat, 26 - 3060 Bertem
Tel: 0476/44.10.44 – E-mail: secretary@sbmhs-bvoog.be
Website: www.sbmhs-bvoog.be – N° Enterprise: 428.739.109

4. Pulmonary oxygen toxicity: at this time, there is very little known as to a possible increased
sensitivity of the pulmonary tissue to the toxic effects of oxygen; therefore, a prudent
attitude would be that technical diving (with prolonged breathing of hyperoxic gas, with apO2 of 1.3 ATA or higher) should be avoided. Simple “nitrox” diving (whereby a maximum
pO2 of 1.4 ATA is only breathed for short periods, at the deepest part of the dive) should
not present any problem.
5. Decompression sickness: even less is known about the possible alteration of the “bubblefilter” function of the lung after COVID-19 pulmonary infection. This may imply that the riskfor decompression sickness could increase significantly. It has been shown that after
deeper recreational dives (close to the No-Decompression-Limit – NDL – of the divecomputer, or with mandatory decompression stops), in 70-90% of cases, inert gas bubbles
can be detected. These bubbles circulate in the venous blood, and are filtered out by thepulmonary capillary circulation and thus usually do not cause decompression sickness. If
the lung “bubble filter” would become less efficient, these bubbles could pass into thearterial circulation (“arterialise”), comparably to divers with a Patent Foramen Ovale, andcause cerebral, vestibular or other types of decompression sickness. Therefore, a prudent
attitude would be that divers who have suffered from pulmonary symptoms of COVID-19,
limit their dives temporarily (or definitively) to well within the NDL of their computer (sothat at no moment during the dive, the computer indicates mandatory decompression
stops).
These recommendations are made on the basis of scientific data available on April 12th, 2020.
It is likely that these will evolve if and when new data or insights become available.

For the Board of SBMHS-BVOOG:(signed)(signed)(signed)Dr Guy Vandenhoven
PresidentDr Peter Germonpre
Board member

Dr Jean-Pierre Rezette
Board member

Secretaria(a)t: Sigrid Theunissen – Weygenstraat, 26 - 3060 Bertem
Tel: 0476/44.10.44 – E-mail: secretary@sbmhs-bvoog.beWebsite: www.sbmhs-bvoog.be – N° Enterprise: 428.739.109