To date over 21 million people in the UK have had proven Covid-19 infection. The true number is thought to be much higher due to a variety of reasons including testing not being easily available in the early months of the pandemic, those with no or minor symptoms not testing and those that did failing to report their positive result to the NHS.
This could mean that well over half of the UK population have so far been infected with Covid-19.
Significance of Covid-19 infection for divers
It is now well known that
Covid-19 can seriously damage the lungs, heart, and other organs in
the body. For those that survive Covid-19 (probably 98% of those
infected) we do not know how many will have significant permanent
damage and how many will only have temporary damage, but for an
unknown length of time. The number of patients diagnosed with Long
Covid is increasing. Even those with ‘mild’ symptoms have been
identified as having lung damage on chest x-rays and CT scans.
Lung damage in divers is a
significant risk factor for pulmonary barotrauma (causing e.g. a
pneumothorax or CAGE) on ascent in the water. The lung damage may
also increase the risk of developing a right-to-left shunt leading
to decompression illness in a similar manner to those with a Patent
Foramen Ovale (PFO.)
Heart damage, which may go
unnoticed on dry land, may decrease exercise tolerance, increase the
risk of developing cardiac arrhythmias and myocardial infarction
underwater. It may also lead to a decompensation with exercise
causing hypoxia. An inadequately functioning heart will increase the
risk of Immersion Pulmonary Oedema, which is thought to be the
largest cause of cardiac diving fatalities, even before the Covid
Covid-19 infection is
constantly changing. The early variants often led to severe symptoms
and a relatively high fatality rate along with a significant risk of
developing Long Covid. In the last 3-6 months the predominant
variant has been Omicron, which whilst being highly contagious has a
much lower risk of severe illness and causing lung / heart damage.
Research suggests that
40-80% of people who have not had any Covid-19 related symptoms may
have actually had a mild form of the illness without realising it.
Recently in the UK freely available lateral flow tests have
identified many people with asymptomatic Covid-19 infection,
especially with the omicron variant. Therefore, there is a case to
argue that everyone should be considered to have had Covid-19
infection and should seek medical assessment for fitness to dive.
Reasons for needing a medical assessment
There is little regulation
in recreational diving and often qualified divers are free to dive
without any approval systems. However, there are several times when
some form of medical assessment will be required:
All training agencies,
when commencing a course, insist on the student completing a medical
health declaration form. If this form indicates that a medical
assessment and a physician’s clearance to dive is required, then
this must be obtained before any in water activity.
providers may also require a health declaration to be completed and
a medical certificate provided if indicated, for their clients.
Travel & Diving insurance
companies may require a medical certificate if the diver has, or
had, any medical problems.
Professional level divers
e.g. instructors / divemasters on commercial recreational diving
instruction courses in the UK must have an annual HSE diving medical
Personal choice for the
diver’s own wellbeing.
Health declaration forms
When learning to dive or
taking diving courses the training agency usually requires a health
declaration form to be completed. For commercially organised courses
e.g. PADI, RAID, SSI, SDI the form used is the (World) Recreational
Scuba Training Council (RSTC) medical declaration.
This form was updated in
2020 and the first question was about being diagnosed with Covid-19.
A positive response then required a doctor’s sign off before any in
water activity. Due to the standards of many training agencies this
would then require an annual medical assessment, even if no damage
from the Covid-19 infection had been identified. In January 2022 a
revised form was issued which stated that after a satisfactory
medical assessment following Covid-19 infection, then no further
annual reviews would be required. Several weeks later in February
2022 a further updated form was published. This removed the
reference to having had a Covid-19 infection and the only question
that may apply is now “Symptoms affecting my lungs, breathing, heart
and/or blood in the last 30 days that impair my physical or mental
performance”. The implication being that 1 month after any Covid-19
infection the person will always be back to normal. This is contrary
to experience to date!
diving websites reveals that all four of the RSTC medical
declaration forms are currently being used, so divers may be
required to complete any of these forms with or without reference to
having had Covid-19. The prudent diver will need to clarify with
their chosen dive provider before arriving for the diving session,
or disappointment may result when diving is refused.
In the UK there are dive clubs e.g.
BSAC, SSA that also provide recreational diving tuition. They use
the UKDMC medical declaration form. Again, there is a specific
question regarding having had Covid-19. If the answer is positive,
then the diver must be assessed by a UKDMC medical referee to be
approved to dive.
This medical certificate
does have a facility to indicate that medical issues may be cleared
for an extended period or even indefinitely without needing further
annual approval by the medical referee. These extended certificates
may not be recognised by other diving providers or may not comply
with local laws where everyone is required to have an annual medical
Guidelines for the medical assessment of divers post Covid-19
Dr Frank Hartig’s case
Belgium Society of
Diving’s guidance on assessing divers – 12th April 2020
UC San Diego Guidelines
for Evaluation of Divers during COVID-19 pandemic – 8th
European Underwater &
Baromedical Society’s guidance on assessing divers – 21st
5) UKDMC guidance and
score card for assessing risk -
30th June 2020, updated February 2022.
All recommended that the diver would need to be symptom free and have regained their pre-covid level of fitness before resuming diving and usually after medical assessment
Summary of recommendations
No diving 1 month#.
No tests required.
No diving 1 month#.
No diving 1 month#.
Seek advice of referee.
No diving 1 week#.
Mild symptoms only.
No diving 2-3 months#.
No diving 3 months#.
No diving 1 month#.
Tests likely to be needed.
See Diving doctor 10 days after full
No diving 3 months#.
Echocardiogram if cardiac
No diving 3 months#.
Lung diffusion capacity tests.
May need echocardiogram, CT, blood
Not covered by this guidance as
multiple variations and complications likely.
Will most likely need full
cardiological and pulmonary evaluation by specialists.
# after full recovery
* Exercise test with oxygen saturation monitoring
The UKDMC took a different
approach by designing a scorecard for divers to use, to assess their
likely risk of having ongoing lung or heart damage. Points are
issued for various symptoms, tests, hospitalisation, and assistance
required for breathing, to give an overall score.
significant damage to heart & lungs
No indication of
5% (low risk)
Positive test but no
Up to 50% (moderate
Mild symptoms, not
Over 50% (high risk)
48 and above
For those that only had mild
symptoms for less than 7 days or asymptomatic disease they also have
a points system to indicate who needs a Post Covid medical
assessment, by one of their referees in their February 2022 update.
What might a medical assessment consist of?
Most diving doctors would
recommend the following as a minimum:
questionnaire to identify significant medical problems
Review of any symptoms
Clarification that full
fitness has returned
Risk assessment of the
type of diving planned e.g. holiday diving only, technical diving,
Review of GP / hospital
records where appropriate
Annual blood pressure
Lung function tests
Exercise test with oxygen
Those that required
hospital treatment will probably need a chest CT scan and an
echocardiogram as well
Fitness to participate in
recreational activities may not be a local NHS priority and any
tests required to establish fitness to scuba dive may have to be
done, and paid for, in the private medical sector. They are likely
to cost several hundreds of pounds.
HSE Guidance on validity of HSE diving medical
certificates (MA2) for UK professional divers
In the UK instructors,
divemasters & rescue divers working on commercial recreational
diving courses must comply with certain legal requirements:
All divers must have a full medical in
accordance with the requirements of MA1.
Additionally, under the Diving at Work
- divers must not dive in a diving
project if they know of anything, including any illness or
medical condition, which makes them unfit to dive; and
- under certain circumstances
following illness or injury, divers must be re-examined by an
approved medical examiner of divers (AMED) to assess their
fitness to return to work.
Specific guidance (updated 9th May 2022) in relation to COVID-19
infection is provided below:
recovery time before diving can resume
Return to work
assessment by an AMED required
Previously asymptomatic and
tested positive for coronavirus
7 days after
initial positive test
Previously had mild symptoms (no
shortness of breath or chest pain) that
improved within a week with complete recovery. Back to your
usual levels of fitness
7 days after full resolution and returned to pre-covid level of fitness
Previously had moderate symptoms.
Back to your usual levels of fitness
Must have regained pre-covid level of fitness and after an examination by an AMED
Previously had severe symptoms
requiring hospitalisation. Back to your usual levels of
Must have regained pre-covid level of fitness and after an examination by an AMED. Further tests almost certainly needed
So those who were truly
asymptomatic or only had mild symptoms for less than 7 days can
self-certify themselves as fit to return to diving after 7
being symptom free, all others will need an assessment by an AMED.
Further infection with Covid-19
A second or further
infection with Covid-19 is very possible due to the mutation of the
virus producing different strains. Although often this further
infection is symptomatically mild, it cannot be guaranteed not to
produce ongoing lung or heart damage, just because the prior
infection did not do so. Therefore, further episodes of infection
will need medical reassessment for fitness to dive.
Whilst there is no doubt
that completion of vaccination courses does offer protection against
severe illness, this is not guaranteed to protect against further
infections. Therefore, vaccination status does not influence the
advice on the need for medical assessment post Covid-19.
Covid-19 infection is
common, potentially life threatening, risks ongoing ill health and
increases the risk for scuba diving. Sadly, the consequences of a
Covid-19 induced problem whilst diving are likely to be extremely
serious and probably life threatening. Caution is required before
divers return to diving, which should certainly not happen until
completely symptom free and back to pre-covid levels of fitness.
Thorough medical assessment is advised for the diver’s wellbeing. As
diving health declarations may specifically ask about Covid-19
infection, many divers in the UK are likely to require medical sign
off before diving. Failure to declare Covid-19 infection may
invalidate insurance claims.
Medical services in the UK
are likely to be very busy for the foreseeable future and less
doctors are prepared to undertake sport diving medical assessments.
This will inevitably result in delays in accessing fitness to dive
medicals, so it is essential that the diver allows plenty of time to
get medically assessed, before resuming diving, or booking a diving
Mark Downs. HSE AMED 01-13-09. Updated: March 2022