Recommendations for Demonstrators, Law Enforcement Agencies, and Public Health Agencies for Reducing SARS-CoV-2 Transmission During Civil Protests

The US Surgeon General and other public health experts have raised alarms that civil unrest during the coronavirus disease 2019 (COVID-19) pandemic may increase community transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). ¹ This increased risk may adversely affect all in attendance, including protestors, law enforcement officers, journalists, and bystanders. To date, no comprehensive and specific safety recommendations for these activities address what the 3 main stakeholders—protestors, law enforcement agencies, and public health agencies—can do to reduce the risk of infection for people who attend civil protests, their household members, and the broader community. We provide recommendations aimed at reducing virus transmission during civil protests. We focus on the role of protesters, law enforcement personnel, and public health officials in reducing transmission.

Background

Epidemiologic studies indicate that large, crowded, and loudly expressive events held indoors that involve shouting or singing are potential “super spreader events” (ie, events in which a virus spreads more than usual) that can increase SARS-CoV-2 transmission. ^{1 -3} Experts and observations suggest rates of spread may be lower in outdoor environments than indoors. ^4,5 However, many state governments regard outdoor spectator sporting events as risky because they rely on close seating, shouting, and cheering. Many infections are asymptomatic, thus making close physical proximity to potentially infected people hazardous. ⁶ The Centers for Disease Control and Prevention (CDC) describes large, in-person events where it is difficult to maintain a 6-foot distance as “highest risk” whether they are held indoors or outdoors. ⁷

Do protests cause increased spread of SARS-CoV-2? One US population study (pre–peer review) suggested that COVID-19 rates in counties where protests were reported were 35% higher than in nonprotest counties, even after controlling for rollbacks in social-distancing restrictions. ⁸ However, an analysis of 242 US cities (pre–peer review) found no evidence that the protests contributed to increases in COVID-19 cases among the entire population of the cities during the 35 days after the protests. ⁹ One study submitted for peer review suggests that outdoor, mass-gathering, political rallies held in August and September 2020 in the United States increased the incidence of COVID-19 infections. ⁹ The average incidence of infections in the 2 weeks after the rallies increased 1.5-fold as compared with the previous period in counties where mass outdoor rallies occurred. ¹⁰ Comparatively, the national average incidence of SARS-CoV-2 infections increased 1.02-fold during the same period. ¹⁰

Tear gas and other lachrymators, such as pepper spray, have been used at many protests. Collectively, these agents cause sneezing, coughing, and tearfulness that may increase SARS-CoV-2 spread among protestors and law enforcement officers. ^11,12 Military recruits exposed to tear gas showed nearly 2.5 times higher risk of clinically diagnosed acute respiratory illness after exposure as compared with the period before exposure, with increasing risk at higher exposure concentrations. ^13,14 Eye and airway pain induced by these agents may increase the likelihood that people will touch their faces, which could accelerate the spread of SARS-CoV-2.

How Can People Attending Group Protests Reduce the Risk of SARS-CoV-2 Spread?

We provide recommendations that people attending protests should follow to reduce the risk of SARS-CoV-2 spread. Before attending a protest, protestors should check for signs and symptoms of COVID-19 (Box 1). During the protest, the key element under the control of protestors is to keep their face masks on, maintain 6 feet of physical distance from people outside of their household (especially staying away from people not wearing a face mask), and use hand sanitizer liberally. Wearing goggles may minimize the risk of conjunctival inoculation of SARS-CoV-2 and protect against tear gas and pepper spray, the use of which is unpredictable at protests. People at high risk for more severe clinical forms of COVID-19 ¹⁵ should consider avoiding attending protests.

Box 1. Recommendations for reducing SARS-CoV-2 risks before, during, and after a protest.

Before Attending a Protest

• Do not attend a protest if you have any symptoms of COVID-19, such as shortness of breath, cough, sore throat, diarrhea, loss of smell or taste, or headache.

• Check for fever and stay home if temperature is >100.4 °F (38.0 °C).

During a Protest

• Wear face masks covering mouth and nose at all times.

• Attend protests with people with whom you have sheltered in place, such as household members.

• Maintain at least 6 feet of physical distance (2 arms’ lengths) from people who are not in your household.

• Carry hand sanitizer, use it often, and share it liberally with others.

• Wear goggles to protect against tear gas and pepper spray and to minimize the risk of conjunctival inoculation of SARS-CoV-2.

• Carry extra face masks to distribute to others who are not wearing face masks.

• Consider alternatives to loud chanting, singing, and shouting, including using drums and other noise makers and carrying signs. Consider the effect of contemplative, soulful, soft chanting as a dramatic and safe way to protest in public.

After a Protest

• Wear a face mask and physically distance from high-risk household members while at home for 14 days.

• Check temperature and monitor for symptoms of COVID-19 daily for 14 days.

• A quarantine can end after 10 days if no symptoms have occurred during daily monitoring or after 7 days if a diagnostic test for SARS-CoV-2 collected within the previous 48 hours is negative and if no symptoms were experienced during daily monitoring.

• Consult a health care provider and obtain SARS-CoV-2 testing if fever (>100.4 °F [38.0 °C]), shortness of breath, cough, sore throat, diarrhea, loss of smell or taste, or headache develop.

• Consider SARS-CoV-2 testing if you were not wearing a face mask or were in close contact with nonhousehold members not wearing face masks.

Do protesters need to quarantine or be tested after attendance? CDC does not address these questions specifically in current documents, and local public health jurisdictions have differing recommendations for managing infection risk after attending a protest. The Los Angeles County Department of Public Health issued guidance that people attending protests who had close contact with nonhousehold members should self-quarantine for 14 days (stay home, separate themselves from others, and monitor for symptoms). ¹⁶ However, New York City’s health leadership advised protesters to test for SARS-CoV-2 but did not specifically recommend self-quarantine. ¹⁷

We believe no evidence is available to recommend that people who attend a protest quarantine themselves. We recommend wearing a face mask and physical distancing from household members for 14 days after attending a protest when household members are at high risk for severe COVID-19, such as adults aged ≥60 or people with diabetes, hypertension, or underlying heart and lung disease. ¹⁵ Demonstrators should check their temperature and monitor themselves for those 14 days for symptoms of COVID-19. For people who choose to quarantine, CDC provides acceptable alternatives to a 14-day quarantine. ¹⁸ A quarantine can end after 10 days if no symptoms have occurred during daily monitoring. Alternatively, a quarantine can end after 7 days if a diagnostic test for SARS-CoV-2 collected within the previous 48 hours is negative and if no symptoms were experienced during daily monitoring. In both scenarios, protestors should continue to monitor daily for symptoms, wear a face mask, and maintain physical distancing from household members through 14 days. If symptoms or a fever >100.4 °F (38.0 °C) develop within 14 days, protestors should isolate themselves from their household members, consult a health care provider, and obtain SARS-CoV-2 testing. We recognize that some people attend protests continually during extended periods. These recommendations should continue as long as people are attending protests. These recommendations are consistent with CDC guidance because attendance at a protest does not itself constitute the close contact with someone who has COVID-19 that requires quarantining for 14 days. ¹⁹

We recommend that people who did not wear a face mask or were in close contact with nonhousehold members not wearing face masks obtain viral diagnostic testing 5-7 days after they attend a demonstration. They should follow the aforementioned recommendations for physical distancing and mask wearing while they await test results. They should notify any fellow protestors, isolate themselves from their household members, and notify a physician if they receive a positive test result. Although a negative test approximately 7 days after exposure indicates a decreased likelihood that one is infected, it does not eliminate completely the possibility that one is infected. ^20,21

Recommendations about testing of asymptomatic people should be updated as more is learned about the risk of contracting SARS-CoV-2. Furthermore, each protest attended represents a single potential exposure. Risk of SARS-CoV-2 infection accumulates during these exposures. Research is needed to inform how often potentially exposed people should get a test.

How Can Law Enforcement Agencies Reduce the Risks of SARS-CoV-2 Spread?

We provide recommendations that law enforcement officers should follow to reduce the risk of SARS-CoV-2 spread during and after protests (Box 2). Both before and after protests, face masks that remain on are essential for source control; they protect others and may also protect the wearer from infection. ^22,23 Law enforcement officers should wear face masks covering their mouth and nose at protests. We recommend that law enforcement provide clean masks to any detained protestors who do not have one, for the protection of both protestors and law enforcement officers.

Box 2. Recommendations for law enforcement officers to reduce transmission of SARS-CoV-2.

• Wear face masks covering mouth and nose at all times.

• Avoid the use of tear gas or pepper spray at peaceful protests.

• Provide clean face masks to detained protestors who do not have them, for the protection of both protestors and law enforcement officers.

• If possible, avoid removing a protestor’s face mask during detention or booking. Care should be taken to minimize exposure risk (social distancing and masking others).

• Avoid seating detained protestors in close contact for more than 15 minutes.

• Because police transport vehicles are often crowded, consider issuing citations and court summons on site.

• When incarceration is required, face masks, handwashing with soap and water, and physical distancing are important.

Because the use of tear gas and other agents may create conditions that accelerate the spread of SARS-CoV-2, we recommend that law enforcement agencies should not use these tools during peaceful protests. ^24,25 Likewise, some procedures commonly used to subdue or arrest protestors—and observed in video and photographic accounts of protests—can increase the likelihood of increased SARS-CoV-2 transmission. These procedures include removing face masks, handcuffing, and seating protestors shoulder-to-shoulder unmasked for prolonged periods in vehicles. These approaches do not permit safe physical distancing, prevent mouth or nose covering, and present more opportunities for airborne transmission and contact with surfaces that may harbor virus. Lastly, although arraignment of protestors may be necessary, confinement in poorly ventilated and overcrowded jails during the COVID-19 pandemic is unhealthy for protesters and corrections officers. ^26,27 Rapid processing and release of nonviolent protesters to return for legal hearings later or issuing citations are safer alternatives to formal detention. Where incarceration is required, face masks and physical distance are important to protect all from SARS-CoV-2 in a jail environment.

How Can Local Public Health Agencies Reduce the Risk of SARS-CoV-2 Spread During and After Protests?

Protests are occurring frequently in metropolitan areas across the country, and we provide the following recommendations for public health departments to reduce the risk of SARS-CoV-2 spread during and after protests (Box 3). Public health departments should issue and publicize official guidance to reduce SARS-CoV-2 spread at protests, such as the guidance that the Los Angeles County Department of Public Health issued to ensure the health and safety of protestors. ¹⁶ Before protests, public health officials should coordinate with organizers and circulate social media campaigns to improve adherence to face mask use, physical distancing, handwashing, and testing and treatment recommendations. Public health agencies can partner with community leaders, community health partners, and local media to disseminate messages that emphasize harm reduction during protests as a feasible and effective tool to prevent COVID-19. They can use the protests to distribute information about prevention and how to get tested, and they can give out face masks. After protests, public health can again make announcements about COVID-19 prevention that are coordinated with protest organizers and community health partners.

Box 3. Recommendations for public health departments to reduce SARS-CoV-2 transmission.

• Develop and publicize public health guidance to reduce SARS-CoV-2 spread at protests.

• Develop communication strategies with protest organizers to improve adherence to face mask use, physical distancing, handwashing, and testing and treatment recommendations.

• Engage with community leaders, partners, and media to disseminate communications informing protestors that harm reduction during protests is feasible and effective to prevent SARS-CoV-2 spread.

• Masks and information about prevention and testing can be distributed at protests.

Discussion

Protests have the potential to spread SARS-CoV-2. To date, they have not been conclusively demonstrated to have done so, but we are providing recommendations to lower the risk of spread even more than what is possible without these protections. We encourage protestors, law enforcement officers, and public health agencies to engage actively with one another and adopt policies and practices to reduce transmission in their families, communities, agencies, and jurisdictions. Although protestors’ actions can reduce the risk of transmission, protestors do not control some factors that contribute to transmission risk. For example, law enforcement officers largely control the rules of engagement and have crowd control tools, such as tactical maneuvers and riot control agents. ²⁸ Our law enforcement recommendations are in accordance with recommendations provided by the Los Angeles County Department of Public Health. ²⁹

Continued attention to the current protests is needed to document their effect on SARS-CoV-2 transmission. Further research is needed to determine how widely these recommendations are adopted and to make changes in policies to help implement them. SARS-CoV-2 is a novel virus, and the rapidly growing knowledge base instructs us daily. These recommendations should be updated as our knowledge evolves.

ORCID iDs

David P. Eisenman, MD, MSHS https://orcid.org/0000-0003-4320-1331

Dorothy J. Wiley, PhD, MPH, RN https://orcid.org/0000-0002-9416-473X

Brad H. Pollock, PhD, MPH https://orcid.org/0000-0003-4415-8638