by Kimberly Milhoan, MD
originally published on Romans One website
We’ve written elsewhere how we initially kept our church doors open during the COVID-19 crisis by expanding our food pantry ministry. My pastor husband and I are both physicians. We’ve maintained a vested interest in protecting our church community, as well as members of our household and the public that we have been interacting with. My husband began speaking from the pulpit on infection transmission prevention on March 1 and wrote a letter to our congregation on March 14, when there were no reported COVID-19 cases on our island home of Maui, explaining our decision to hold regular services on March 15. He emphasized hand and respiratory hygiene and asked anyone with suspicious symptoms to stay home. As national guidelines were released and the size of gatherings restricted over the next week, our size allowed us to be one of the last churches on Maui to meet, on March 22. We cleaned all potentially contaminated surfaces. We made hand sanitizer available at the door. We did not serve our usual donuts and coffee. We had congregants pick up their own single-service communion cups. We did not have our usual greeting time. We never pass a collection plate. We extended our food pantry ministry from three days to seven days per week the following day and all activity involving our church became related to that activity.
Over 100 people from our church body regularly participated in this ministry over the two months and we had over 2150 clients in that time frame. As public guidelines changed, we complied with them. Volunteers wore masks and gloves. Visitors were greeted at the door with hand sanitizer and a touchless thermometer. We moved the chairs in the sanctuary so family groups could sit in compliance with social distancing guidelines. If any volunteer had any concerning symptoms, they were required to stay home. Based on extensive medical testing, observations, and interviews we conducted, we had a preliminary picture of a record of safety in our church. Unlike many epidemiologic studies, we had the advantage of intimate knowledge of the behaviors and actions of our community of believers during this time period.
Three different people in church on March 22 were likely infected but either asymptomatic or minimally symptomatic. This correlates well with Hawaii’s peak case count a few days later. All three were working or volunteering extensively in the community at the time, one in the medical profession. Two are married, but none of the three passed the infection on to their spouse or household members. One may have passed the infection on to another through close contact in church that day. However, that person did not pass the infection on to their household. Three other people had either asymptomatic or minimally symptomatic infection sometime during that two month period. All worked full-time throughout, two in the medical profession. Two are married and did not pass the infection on to their spouses or households. Thus, out of over 100 people tested, we have evidence for seven infections in our church body in two months: three were in health care workers, three were in full-time work in the community, and one may have been spread by close contact with someone in the church who was asymptomatic or mildly symptomatic at the time.
An infection in our church may seem like bad news, but let’s also examine the good news. We can only find evidence of probable spread of infection from one person. We cannot find evidence of spread of infection from any of the other six, even to spouses and household contacts. Over ninety other people who had extensive interactions with each other, and over 2150 food pantry clients, have no evidence of infection. The two people who were on-site nearly every day for two months and had interactions with every single person who was infected had no evidence of infection themselves. We had four married couples where one spouse was infected and the other was not. In fact, none of the household members of any of the infected were infected.
What do we make of this? First, contact transmission matters. We can trace a likely infection on March 22 to touching common items, just because we know the behavior of the two individuals involved on that day. Note we cleaned surfaces and then eliminated most ways people touched each other on March 22. It was possible to walk into our church on March 22, touch nothing or no one if you so chose (other than sitting in a chair), participate in the service, and walk back out. We likely had around 160 people participate over two services on that day and no evidence of any other infections. Second, I don’t believe singing matters. We sang on March 22 and we’ve sang together twice a week at our food pantry meetings ever since. We only started wearing masks when guidelines demanded it. Third, host matters. One of the infected was in a high-risk group by age. Despite this, we have had no hospitalizations and no deaths from the infected in our church community or their contacts. Fourth, the window of transmission and conditions for transmission must have to be incredibly perfect. How else can you explain spouses not infecting each other, let alone the myriad of other close contacts? Fifth, there may be something to our ambient temperature and humidity in Maui which decreases risk of transmission and severity of infection. Sixth, we may actually have demonstrated an advantage to not being locked down. Disease transmission seems to go up within households as they spend more time together, but we were all coming and going in our households.
Review of the medical literature on COVID-19 reveals that respiratory transmission is presumed but largely theoretical. An April 20 article in Anaesthesia admitted “the mechanisms and risk factors for [airborne] transmission are largely unconfirmed.” In fact, case reports from different countries early in the outbreak, including the U.S., demonstrate that supposedly high-risk exposures, some of which generated respiratory droplets and aerosols, with inadequate personal protective equipment (PPE), with patients symptomatic enough to be receiving medical care, did not result in a high level of disease transmission to health care workers (HCWs) or other patients. A March 12 article from Taiwan reported that during their SARS experience (and South Korea’s MERS experience), HCWs contracted these corona viruses, like COVID-19, despite never having contact with an infected patient, via fomites, meaning by touching contaminated surfaces. An April 6 letter in the New England Journal of Medicine asserts that the aerosol and surface stability of COVID-19 is similar to SARS, indicating the means of transmission is likely similar.
Recently, the CDC was attempting to downplay the risk of surface transmission (although they’ve since corrected this), while also releasing two case reports regarding disease spread in churches. The first occurred when symptomatic individuals attended gatherings at an Arkansas church on March 6-8, prior to the March 16 release of CDC guidelines to “slow the spread,” where common items were touched and food was shared buffet-style. The second occurred on March 10 when a symptomatic individual attended a choir practice. Much has been made about the risk of corporate singing from this case report, although careful reading reveals changing rooms and moving chairs could have provided a means of contact transmission. The median age of the attendees was 69, so they were a group at high-risk for becoming infected.
Church case reports are easy targets because the members are close-knit and encounters are easy to remember. Neither case report attempted to track where the symptomatic individuals who came to church were initially infected. Both these case reports also occurred very early in this crisis. Most honest people will admit to going to church, work, or other social events with a respiratory virus was commonplace prior to COVID-19. Those who thought they had a “cold” and went to church in Arkansas in early March, prior to any cases being reported in that state, were doing what we all have done. Even though there had been deaths due to COVID-19 in Washington when the choir practice occurred, the first case of COVID-19 was reported in the county where the church was on the day of the practice. Most who are being honest about their actions will confess they didn’t change a lot of their behaviors until later in that week. With the benefit of hindsight, and the public excoriation churches have endured, I doubt many would go to a church event while symptomatic now.
In April, the CDC released a report of disease spread at two family gatherings, followed by church attendance, in Chicago in February and March. Once again, these events occurred prior to a national change in behavior and they demonstrated means of contact transmission (sharing a meal, passing on offering plate). The Lancet released an article in March characterizing three COVID-19 disease clusters in Singapore in February. One involved eleven cases in a tourist group, where common items were touched during shopping. Another involved twenty cases at a work conference where many opportunities for touching common items occurred. The final involved five cases at a church. Four infected individuals attended a church service. Only one out of 142 individuals who attended church that day became infected, when they sat in the same chair as one of the infected individuals at a following service.
I believe there is a bias in negative reporting of disease spread in churches, when there is also ample evidence of disease spread in places of business, hospitals, and nursing homes. There is also an attempt to propose unique mechanisms of disease spread (talking, breathing, singing), when mechanisms for contact transmission are evident with careful reading. We changed a lot of practices in our church but we might have had someone who was asymptomatic or mildly symptomatic give the virus to one person because they touched common items. We have no evidence that person infected anyone else on that day, despite their prolonged presence before, during, and after church, coming into contact with most people who were in the church on that day.
COVID-19 is challenging because viral load occurs early in infection and people are likely infectious when they have no or minimal symptoms. In order to prevent the spread of any respiratory virus, including the flu or the common cold, we should always wash our hands before and after touching our faces or anything anyone else touches, we should cover our coughs and our sneezes, and we should clean environmental surfaces. What is different with COVID-19 is that if we have any hint of symptoms, we should stay home. We have done this in our church and have had no evidence of infection spread after March 22.
As careful as we are, however, we are still going to spread this virus. The good news is, according to the CDC’s latest numbers, at least 35% of us will be asymptomatic and case fatality rate (CFR) for those who are symptomatic is 0.4%. That means if one-thousand people are infected, 350 will not have symptoms, 650 will, and four will die. Life is inherently risky. We can do everything “right” and still transmit this virus. Everyone needs to determine their own level of risk tolerance. If you are under 65 and have no co-morbid conditions, such as obesity, high blood pressure, diabetes, or heart disease, your risk is low. The seven people in our church who are now demonstrating antibodies, except for the public health department scrutiny they’ve recently endured, are pretty happy about it, and creatively volunteering to be the servers at any buffets we might have. If you are in, live with, or care for someone in a high-risk category, you have to be more careful. The majority of people over 65 in our church have chosen to be involved, preferring that to staying home in isolation. Only one became infected, through volunteer work outside the church, and never had to be hospitalized.
We will soon open our doors to regular worship. Many of our food pantry clients, as well as the daily Alcoholics Anonymous meeting attendees, claim they will be there. We led more people to Christ and gave away more Bibles in those first two months of ministry during COVID-19 than the previous six years my husband has been a pastor. Paul said in 1 Corinthians 16:9, “a wide door for effective service has opened to me, and there are many adversaries.” The public will look to scrutinize, criticize, and demonize. We believe we have demonstrated we can gather safely, not out of any demand for rights or inappropriate faith claims, but out of obligation to serve those in need, both practically and with the soul-saving gospel of Jesus Christ. “Be strong, and let us show ourselves courageous for the sake of our people and for the cities of our God; and may the LORD do what is good in His sight” (2 Samuel 10:12).
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