Food For Thought

Falling leaves and cooler, shorter days conjure memories of the changing seasons and the holidays.   And as we proceed into November and December, within the context and framework of an ongoing global pandemic, it is clear that this ‘new normal’ has found its way into every aspect of our lives.  This time of the year is typically characterized by our desire to gather socially for holiday related events either hosted privately or as a corporate/business event.  So it begs the question—should we gather or not?

Recent alarming nationwide case trends and ongoing guidance from the Centers for Disease Control and Prevention (CDC) as well as other globally-recognized public health expert authorities, in unison agree that gathering together for the holidays is a very risky proposition.  With the country’s COVID-19 case count approaching 8.2 million and the death toll now over 219,000, it is no surprise that the consistent recommendation is that celebrating virtually or with members of one’s own household poses the lowest risk for COVID-19 transmission during the holiday season.

Consequently, in-person events that involve individuals from outside of the same immediate household pose varying degrees of risk and should be carefully considered.   State and local guidelines continue to provide local authority with respect to gathering size limits and other logistical gathering requirements and mandates.  However, despite the facts and the mandates, many will weigh the risks, benefits and alternatives and will still opt to gather.  With that in mind, for those who are intent on proceeding with gathering, information-driven decision making may help create venues where at least some of the risk might be mitigated.

COVID-19 is a highly contagious infectious viral pathogen that is spread through the air, through close, prolonged physical contact.  It can survive for varying amounts of time on hard surfaces that are not appropriately cleaned and disinfected.  This novel coronavirus thrives in environments where people gather together, fail to practice social/physical distancing, don’t wear appropriate face coverings and will not self-isolate when sick or potentially exposed/infected.

Because a large percentage of infected individuals will have mild symptoms or no symptoms at all and because certain testing platforms still have false negative rates approaching 35%, it is impossible to create or guarantee a 100% COVID-free space for what the CDC calls ‘congregant gathering events’.

This is not intended to promote gathering together, but to offer information that event hosts and planners might logistically consider in several areas—the guest list, the venue, the day of the event, and the post-event monitoring.

Make Your List And Check It (At Least) Twice

In the COVID-era, checking your guest list must be considered a rate-limiting step.  In fact, checking your guest list only once prior to the event may not be enough.  Likewise, it is essential that for events during the pandemic, you are clear that only invited guests will be permitted inside the event venue.  Additionally, the size and composition of the guest list translate into creating a gathering event that is either ‘high risk’ or ‘risk reduced’.  Remember that no gathering should be considered risk-free and that the CDC maintains the recommendation that same-household and virtual gathering create the lowest risk environments.   However, in the context of social gathering should you choose to host or attend a congregant gathering event during the pandemic, size does matter and the smaller the guest list the better.  Even in local jurisdictions where gathering limits are large, a smaller gathering size has multiple benefits including easier logistics with respect to communicating pre-arrival expectations, conducting event-arrival screenings and temperature checks, venue seating and other arrangement and post-event and/or post-exposure communication contact tracing.  

It is also important to know the points of origin of all invited guests along with their mode of travel and where they will be staying upon their arrival.  Individuals traveling from designated COVID ‘hot spots’ should be allowed to attend with extreme caution.  Pre-travel screening should also help both host and guest identify potential high-risk comorbidities such as hypertension, diabetes, cardiovascular disease and compromised immune system (due to immunotherapy, cancer and certain other diseases).  Additionally, individuals should make every effort to self-isolate for at least one week prior to the scheduled event.  Ideally, guests should have a documented negative COVID-19 screening test 72-hours prior to arrival.  Preferably, this test should be a PCR test as the antigen tests are far less accurate.  Regardless of testing platform, it is essential for hosts and prospective attendees to understand that testing may accurately identify the infected, but still may miss those who are not, which ultimately places everyone at the gathering at risk.  Communicating these realities, expectations and/or requirements several weeks prior to the event gives prospective guests every opportunity to make decisions about attending as well as providing time for those who opt-in to attempt to comply.   

Location Matters

The ideal social gathering venue should be outdoors which may be logistically challenging in many locations due to venue location and/or weather.  If outdoor gatherings are not feasible or practical, indoor venues should be well-ventilated and preferably, windows should be open.  Additionally, creating a ‘mixed’ venue with both indoor and outdoor spaces is preferable to a strictly indoor venue.  Regardless of the venue, seating and other points of gathering within the venue space should promote appropriate social/physical distancing of 6-feet or more.  Event hosts, organizers and venue managers might consider space designs that, in fact, do not allow for seating as it tends to encourage increased duration for close gathering spaces.  Additionally, the venue should have easily visible and accessible methods of hand sanitizing/hand washing and visible reminders regarding face covering and social/physical distancing. Event hosts, planners and managers should also consider having ‘circulating’ staff to keep hard surfaces cleaned and disinfected and to even provide tactful verbal reminders regarding social/physical distancing and face coverings.

Remember, even with the best pre-emptive planning with respect to the guest list and guests’ individual due-diligence with respect to pre-event isolation and testing, particularly in indoor venues, face coverings should still be worn by all guests and event staff during the event as the safest best practice in congregant gathering settings.

Good Advice For ‘Go-Time’

The invited guests have been engaged, informed, and hopefully compliant with host requests.  The venue has been optimized from a seating and sanitization standpoint.  I’s have been dotted and T’s have been crossed and event host has confirmed that they are ready for the guests to arrive.  Now comes the challenging and critical task of engaging guests as they arrive and desire entry.  First, there should only be one entry access point.  At that entry point, similar to many current workplaces and schools, all individuals should complete a pre-entry screening questionnaire affirming that they have been fever-free, symptom-free, and have had no known contact with infected individuals or individuals who have been tested for whom the results are not know.  If at all feasibly or logistically possible, all arriving guests should have a rapid COVID-19 screening test administered prior to entry into the congregant gathering event.  On-site COVID testing should be conducted in a space that is adjacent to but not obstructing the entry point.  Guests should not be encouraged to gather together while waiting for test results and you may want to work with event planners to coordinate the most practical way to ‘manage’ guests while they are waiting for test results.  The entry processes should ideally also apply to all non-guest attendees such as caterers and other event staff.  If the event is being held at venue not managed by the host, the host should complete a due diligence assessment to ascertain the venue’s processes and procedures with respect to the screening, health, safety and contact tracing mechanisms.  The venue should be required to provide a list of all event staff as well as the date of the employee’s last COVID-19 screening test.  Venues that are unable to provide this information should be considered high risk and sub-optimal from a health and safety standpoint and hosts should give serious consideration to selecting an alternative venue.

If an invited guest tests positive upon arrival, the individual should be refused admittance and directed to their home for self-quarantine.  In general, individuals who should not attend or be admitted upon arrival include:

1.    Individuals that have a fever (T>100.0) or who are sick on the day of the event

2.    Individuals at high risk of serious complications of COVID-19 infection based on age, pre-existing medical conditions and/or a known history of a compromised immune system

3.    Individuals exposed to others with COVID symptoms and/or who have been tested for COVID-19 for whom the results are not known

4.    Individuals whose on-site screening questionnaire is positive for increased COVID infection risk.

The event host should likewise consider the ‘status’ of guests who are traveling from high risk locations and/or who have not been able to comply with pre-arrival recommendations.  

After The Party

I have fond collegiate memories of the fun attached to the event after the main event—the ‘after party’.  In this case, the after party is the opportunity to encourage all of your invited guests to consider another COVID-19 screening test upon their return to their point-of-origin.  This test should be administered no sooner than 72-hours after the gathering event has concluded and again a PCR test is preferable to the antigen test which may be more readily available but appears to be inherently less accurate.

You may consider contacting your guests directly at some point after the event to ascertain the development of symptoms and/or you might consider creating an email account dedicated to communication between host and guests.  Your after-party plan should also include the plan to notify guests and your local health department regarding guests who either test positive for COVID-19 or develop symptoms after the congregant gathering event.  

‘New Normal’, New Responsibilities

Now I know what you’re thinking—either it simply doesn’t take all of that for me to host a party, or, that’s way too much work, why bother?

The truth is that it is very labor intensive because the nature of this global pandemic requires hyper vigilance and an attention to detail.  With no effective post-infection treatments, no vaccine, persistent sub-optimal public health contact tracing and response capabilities, and, an alarming trend in new cases, holiday gatherings must assume a far more aggressively proactive posture.  If these congregant gathering event guidelines provide a ‘hard stop’ deterrent, then they have achieved an important goal—to provide data-driven guidance to supplant purely emotion-fueled decision-making.

If these guidelines combined with the fact that the only safe gathering still appears to be a ‘virtual’ gathering, provide you with what you believe is a workable plan, then the encouragement would be to be steadfast and situationally aware—and ready to end the event should the venue or the guests suddenly become compromised and unsafe.

Regardless of the planning and precautions, the risks are real as there is no way to guarantee the health and safety of guests, hosts, and staff.  The stakes are high in that even individuals with seemingly low risk can still get very sick.  Likewise, there is no disputing the fact that a large percentage of super-spreader events have been linked to both indoor and outdoor congregant gathering events.  Should you plan to host a gathering this holiday season, keep it small and keep it simple in order to keep it as safe as possible understanding that the safest approach to this holiday season be simply be to not gather in-person at all.

Christopher T. Conti, MD is an emergency physician and concierge physician working at Connected Health in Wexford, PA. He is also the Lead Pastor of Emmanuel Pittsburgh, author and community advocate for social and health equity and justice.

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