Declaration of Dr. LaQuandra Nesbitt — CHBC v. Bowser

Record facts

U.S. District Court for the District of Columbia · No. 1:20-cv-02710-TNM · Doc. 40-1 · 2020-10-09 · Docket on CourtListener

Full text

UNITED STATES DISTRICT COURT 
FOR THE DISTRICT OF COLUMBIA 
CAPITOL HILL BAPTIST CHURCH, 
Plaintiff, 
v. 
MURIEL E. BOWSER, et al., 
 
Defendants. 
Civil Action No. 20-2710 (TNM) 
 
DECLARATION OF LAQUANDRA NESBITT IN SUPPORT OF DEFENDANTS’ 
OPPOSITION TO PLAINTIFF’S MOTION FOR A PRELIMINARY INJUNCTION 
I, LaQuandra Nesbitt, pursuant to 28 U.S.C. § 1746, affirm that I am over 18 years of age 
and competent to make the following Declaration. 
1. 
I have served as the Director of the District of Columbia Department of Health (DC 
Health) since January 2015. 
2. 
Before becoming Director of DC Health, I was Director of the Louisville Metro 
Department of Public Health and Wellness from July 2011 until January 2015. 
3. 
I received my B.S. degree in Biochemistry from the University of Michigan, my 
medical degree from Wayne State University School of Medicine, and my Master’s Degree in 
Public Health in Health Care Management and Policy from the Harvard School of Public Health.  
I am a board-certified family physician and have served on many commissions and advisory 
groups relating to public health. 
4. 
Under Section II(A) of Mayor’s Order 2020-045 (Mar. 11, 2020), I and the Director 
of the Homeland Security and Emergency Management Agency, Dr. Christopher Rodriguez, 
provide consultation to the City Administrator “to implement any measures as may be necessary 
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2
or appropriate to protect persons and property in the District of Columbia from the impacts of 
COVID-19.” 
5. 
As a practical matter, that means I provide recommendations to the Mayor, the City 
Administrator, and other members of the District of Columbia (the District) government dedicated 
to addressing the public health emergency. This includes recommendations on the development of 
Mayor’s Orders and the guidance the District provides on, among other things, how to protect the 
city’s residents, employees, and visitors from COVID-19. 
6. 
I provided similar recommendations to the ReOpenDC Advisory Group, providing 
my best medical judgment on the provisions that need to be taken to protect against this novel 
coronavirus. 
7. 
In my professional opinion, people are going to get sick and die if the Court permits 
faith-based organizations to conduct worship services outdoors in unlimited size.  
8. 
My professional opinion about the spread of sickness and death is based not only 
on such formal rules as may be established but also on how people behave. It is not appropriate to 
expect that social distancing—people keeping themselves six feet apart—can be maintained when 
unlimited group sizes are allowed to convene, indoors or outdoors. 
9. 
This point has been repeatedly demonstrated during the COVID-19 pandemic. For 
example, I have seen videos of fans in football stadiums in other jurisdictions failing to adhere to 
the “pod concept” and to follow other guidance to which they agreed to submit. Public health 
officials rely on case studies such as these when evaluating whether large outdoor masked events 
would be safe because epidemiologists cannot ethically study this question in a randomized 
controlled trial study design.  
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10. 
This is why, for example, I recommended against the opening of public swimming 
pools this summer, even though chlorine kills the virus. There will be instances of non-
compliance—even by those who are fully committed to complying with the rules—with virtually 
any rule that might be imposed as to social distancing. As public health professionals, we must 
take into account these potential errors or other forms of non-compliance.   
11. 
The current restrictions on mass gatherings under the Mayor’s Orders were 
designed based on how many people could gather with a reasonable risk, taking into account the 
current levels of community spread and rates of transmission. The current information available 
about the risks of transmission of COVID-19 does not support distinctions based on the size of the 
indoor venue or parcel of outdoor land.    
12. 
As noted in Section X.4 of Mayor’s Order 2020-075 and laid out in the two 
attached Morbidity and Mortality Weekly Report articles, published by the Centers for Disease 
Control and Prevention on May 15 and 22, 2020, the traditional activities that happen in places of 
worship such as singing, communion, and other rituals, pose a particular risk that must be taken 
into account when determining the size of mass gatherings that can reasonably be approved by the 
District’s public health authorities. In my professional opinion, these traditional worship activities 
pose a risk for the spread of COVID-19, even when performed outdoors. 
13. 
In fact, DC Health did not initially support the provision in the Mayor’s Order 
allowing places of worship to have a mass gathering of 100 instead of the 50-person limit for other 
mass gatherings during Phase Two of the District’s reopening plan. 
14. 
The District should not increase the size of allowable gatherings to 250 until the 
level of community spread is consistently below a 7-day average of 5 cases per 100,000 people 
per day. The most recent average is 7.54 daily cases.   
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15.
In setting restrictions on gatherings, the District cannot rely on the venue size or
promises of social distancing, or enforcement of those rules by the organizer of a gathering. That 
is why the District has not allowed crowds even in such spacious venues such as Nationals Park, 
the Convention Center, Capitol One Center, the Entertainment and Sports Arena, or the proposed 
Citi Open, which would have been outdoors, even with promises and plans that fans would be 
spread out. 
16.
Although my office has not studied the proposals of Capitol Hill Baptist Church in
particular, the scientific knowledge about COVID-19 is clear that large gatherings, even when 
outdoors and attended by people who wear masks, become progressively more likely to lead to a 
spread of the disease the longer a group is together. There is evidence of an increased risk of 
transmission when those gathered are stationary and in close proximity for 15 minutes or more. 
Thus, any long gathering poses too great a risk of community transition to be safely authorized at 
this time. 
I declare under penalty of perjury that the foregoing is true and correct to the best of my 
knowledge, information and belief.  
Dated: ___________
_______________________________________________ 
LaQuandra Nesbitt, M.D., MPH  
Director, District of Columbia Department of Health 
d<ct,Q,1;1 OJ\fu - \ )f 
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Exhibit A 
 
 
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Morbidity and Mortality Weekly Report 
606	
MMWR  /  May 15, 2020  /  Vol. 69  /  No. 19
US Department of Health and Human Services/Centers for Disease Control and Prevention
High SARS-CoV-2 Attack Rate Following Exposure at a Choir Practice — 
Skagit County, Washington, March 2020
Lea Hamner, MPH1; Polly Dubbel, MPH1; Ian Capron1; Andy Ross, MPH1; Amber Jordan, MPH1; Jaxon Lee, MPH1; Joanne Lynn1; Amelia Ball1; 
Simranjit Narwal, MSc1; Sam Russell1; Dale Patrick1; Howard Leibrand, MD1
On May 12, 2020, this report was posted as an MMWR Early 
Release on the MMWR website (https://www.cdc.gov/mmwr).
On March 17, 2020, a member of a Skagit County, 
Washington, choir informed Skagit County Public Health 
(SCPH) that several members of the 122-member choir had 
become ill. Three persons, two from Skagit County and one 
from another area, had test results positive for SARS-CoV-2, 
the virus that causes coronavirus disease 2019 (COVID-19). 
Another 25 persons had compatible symptoms. SCPH 
obtained the choir’s member list and began an investigation on 
March 18. Among 61 persons who attended a March 10 choir 
practice at which one person was known to be symptomatic, 
53 cases were identified, including 33 confirmed and 20 
probable cases (secondary attack rates of 53.3% among con­
firmed cases and 86.7% among all cases). Three of the 53 
persons who became ill were hospitalized (5.7%), and two 
died (3.7%). The 2.5-hour singing practice provided several 
opportunities for droplet and fomite transmission, including 
members sitting close to one another, sharing snacks, and 
stacking chairs at the end of the practice. The act of singing, 
itself, might have contributed to transmission through emis­
sion of aerosols, which is affected by loudness of vocalization 
(1). Certain persons, known as superemitters, who release 
more aerosol particles during speech than do their peers, might 
have contributed to this and previously reported COVID-19 
superspreading events (2–5). These data demonstrate the 
high transmissibility of SARS-CoV-2 and the possibility of 
superemitters contributing to broad transmission in certain 
unique activities and circumstances. It is recommended that 
persons avoid face-to-face contact with others, not gather in 
groups, avoid crowded places, maintain physical distancing 
of at least 6 feet to reduce transmission, and wear cloth face 
coverings in public settings where other social distancing 
measures are difficult to maintain.
Investigation and Findings
The choir, which included 122 members, met for a 2.5-hour 
practice every Tuesday evening through March 10. On 
March 15, the choir director e-mailed the group members 
to inform them that on March 11 or 12 at least six members 
had developed fever and that two members had been tested 
for SARS-CoV-2 and were awaiting results. On March 16, 
test results for three members were positive for SARS-CoV-2 
and were reported to two respective local health jurisdictions, 
without indication of a common source of exposure. On 
March 17, the choir director sent a second e-mail stating that 
24 members reported that they had developed influenza-like 
symptoms since March 11, and at least one had received test 
results positive for SARS-CoV-2. The email emphasized the 
importance of social distancing and awareness of symptoms 
suggestive of COVID-19. These two emails led many members 
to self-isolate or quarantine before a delegated member of the 
choir notified SCPH on March 17.
All 122 members were interviewed by telephone either 
during initial investigation of the cluster (March 18–20; 
115 members) or a follow-up interview (April 7–10; 117); most 
persons participated in both interviews. Interviews focused on 
attendance at practices on March 3 and March 10, as well as 
attendance at any other events with members during March, 
other potential exposures, and symptoms of COVID-19. 
SCPH used Council of State and Territorial Epidemiologists 
case definitions to classify confirmed and probable cases of 
COVID-19 (6). Persons who did not have symptoms at the 
initial interview were instructed to quarantine for 14 days from 
the last practice they had attended. The odds of becoming ill 
after attending each practice were computed to ascertain the 
likelihood of a point-source exposure event.
No choir member reported having had symptoms at the 
March 3 practice. One person at the March 10 practice had 
cold-like symptoms beginning March 7. This person, who had 
also attended the March 3 practice, had a positive laboratory 
result for SARS-CoV-2 by reverse transcription–polymerase 
chain reaction (RT-PCR) testing.
In total, 78 members attended the March 3 practice, and 
61 attended the March 10 practice (Table 1). Overall, 51 
(65.4%) of the March 3 practice attendees became ill; all but 
one of these persons also attended the March 10 practice. 
Among 60 attendees at the March 10 practice (excluding 
the patient who became ill March 7, who also attended), 
52 (86.7%) choir members subsequently became ill. Some 
members exclusively attended one practice; among 21 mem­
bers who only attended March 3, one became ill and was not 
tested (4.8%), and among three members who only attended 
March 10, two became ill (66.7%), with one COVID-19 case 
being laboratory-confirmed.
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Morbidity and Mortality Weekly Report
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607
US Department of Health and Human Services/Centers for Disease Control and Prevention
Summary
What is already known about this topic?
Superspreading events involving SARS-CoV-2, the virus that 
causes COVID-19, have been reported.
What is added by this report?
Following a 2.5-hour choir practice attended by 61 persons, 
including a symptomatic index patient, 32 confirmed and 
20 probable secondary COVID-19 cases occurred 
(attack rate = 53.3% to 86.7%); three patients were hospitalized, 
and two died. Transmission was likely facilitated by close 
proximity (within 6 feet) during practice and augmented by 
the act of singing.
What are the implications for public health practice?
The potential for superspreader events underscores the 
importance of physical distancing, including avoiding gathering 
in large groups, to control spread of COVID-19. Enhancing 
community awareness can encourage symptomatic persons 
and contacts of ill persons to isolate or self-quarantine to 
prevent ongoing transmission.
Because illness onset for 49 (92.5%) patients began dur­
ing March 11–15 (Figure), a point-source exposure event 
seemed likely. The median interval from the March 3 prac­
tice to symptom onset was 10 days (range = 4–19 days), and 
from the March 10 practice to symptom onset was 3 days 
(range = 1–12 days). The odds of becoming ill after the 
March 3 practice were 17.0 times higher for practice attendees 
than for those who did not attend (95% confidence interval 
[CI] = 5.5–52.8), and after the March 10 practice, the odds 
were 125.7 times greater (95% CI = 31.7–498.9). The clus­
tering of symptom onsets, odds of becoming ill according to 
practice attendance, and known presence of a symptomatic 
contagious case at the March 10 practice strongly suggest 
that date as the more likely point-source exposure event. 
Therefore, that practice was the focus of the rest of the inves­
tigation. Probable cases were defined as persons who attended 
the March 10 practice and developed clinically compatible 
COVID-19 symptoms, as defined by Council of State and 
Territorial Epidemiologists (6). The choir member who was ill 
beginning March 7 was considered the index patient.
The March 10 choir rehearsal lasted from 6:30 to 9:00 p.m. 
Several members arrived early to set up chairs in a large 
multipurpose room. Chairs were arranged in six rows of 
20 chairs each, spaced 6–10 inches apart with a center aisle 
dividing left and right stages. Most choir members sat in their 
usual rehearsal seats. Sixty-one of the 122 members attended 
that evening, leaving some members sitting next to empty 
seats. Attendees practiced together for 40 minutes, then split 
into two smaller groups for an additional 50-minute practice, 
with one of the groups moving to a smaller room. At that 
time, members in the larger room moved to seats next to one 
another, and members in the smaller room sat next to one 
another on benches. Attendees then had a 15-minute break, 
during which cookies and oranges were available at the back of 
the large room, although many members reported not eating 
the snacks. The group then reconvened for a final 45-minute 
session in their original seats. At the end of practice, each 
member returned their own chair, and in the process congre­
gated around the chair racks. Most attendees left the practice 
immediately after it concluded. No one reported physical 
contact between attendees. SCPH assembled a seating chart 
of the all-choir portion of the March 10 practice (not reported 
here because of concerns about patient privacy).
Among the 61 choir members who attended the March 10 
practice, the median age was 69 years (range = 31–83 years); 
84% were women. Median age of those who became ill was 
69 years, and 85% of cases occurred in women. Excluding 
the laboratory-confirmed index patient, 52 (86.7%) of 
60 attendees became ill; 32 (61.5%) of these cases were 
confirmed by RT-PCR testing and 20 (38.5%) persons were 
considered to have probable infections. These figures corre­
spond to secondary attack rates of 53.3% and 86.7% among 
confirmed and all cases, respectively. Attendees developed 
symptoms 1 to 12 days after the practice (median = 3 days). 
The first SARS-CoV-2 test was performed on March 13. The 
last person was tested on March 26.
Three of the 53 patients were hospitalized (5.7%), including 
two who died (3.8%). The mean interval from illness onset to 
hospitalization was 12 days. The intervals from onset to death 
were 14 and 15 days for the two patients who died.
SCPH collected information about patient signs and symp­
toms from patient interviews and hospital records (Table 2). 
Among persons with confirmed infections, the most common 
signs and symptoms reported at illness onset and at any time 
during the course of illness were cough (54.5% and 90.9%, 
respectively), fever (45.5%, 75.8%), myalgia (27.3%, 75.0%), 
and headache (21.2%, 60.6%). Several patients later developed 
gastrointestinal symptoms, including diarrhea (18.8%), nausea 
(9.4%), and abdominal cramps or pain (6.3%). One person 
experienced only loss of smell and taste. The most severe com­
plications reported were viral pneumonia (18.2%) and severe 
hypoxemic respiratory failure (9.1%).
Among the recognized risk factors for severe illness, the most 
common was age, with 75.5% of patients aged ≥65 years. 
Most patients (67.9%) did not report any underlying medi­
cal conditions, 9.4% had one underlying medical condition, 
and 22.6% had two or more underlying medical conditions. 
All three hospitalized patients had two or more underlying 
medical conditions.
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US Department of Health and Human Services/Centers for Disease Control and Prevention
Public Health Response
SCPH provided March 10 practice attendees with isolation 
and quarantine instructions by telephone, email, and postal 
mail. Contacts of patients were traced and notified of isola­
tion and quarantine guidelines. At initial contact, 15 attendees 
were quarantined, five of whom developed symptoms during 
quarantine and notified SCPH.
Before detection of this cluster on March 17, Skagit County 
had reported seven confirmed COVID-19 cases (5.4 cases per 
100,000 population). At the time, SCPH informed residents 
that likely more community transmission had occurred than 
indicated by the low case counts.* On March 21, SCPH issued 
a press release to describe the outbreak and raise awareness 
about community transmission.† The press release emphasized 
the highly contagious nature of COVID-19 and the impor­
tance of following social distancing guidelines to control the 
spread of the virus.
Discussion
Multiple reports have documented events involving super­
spreading of COVID-19 (2–5); however, few have documented 
a community-based point-source exposure (5). This cluster of 
52 secondary cases of COVID-19 presents a unique opportu­
nity for understanding SARS-CoV-2 transmission following 
a likely point-source exposure event. Persons infected with 
SARS-CoV-2 are most infectious from 2 days before through 
7 days after symptom onset (7). The index patient developed 
symptoms on March 7, which could have placed the patient 
within this infectious period during the March 10 practice. 
Choir members who developed symptoms on March 11 
(three) and March 12 (seven) attended both the March 3 
*	Skagit County, updated social distancing information. https://skagitcounty.
net/departments/home/press/031620.htm.
†	Skagit County, public health investigating cluster of related COVID-19 cases. 
https://skagitcounty.net/departments/home/press/032120.htm.
TABLE 1. Number of choir members with and without COVID-19–compatible symptoms (N = 122)* and members’ choir practice attendance† — 
Skagit County, Washington, March 3 and 10, 2020
Attendance
No. (row %)
March 3 practice
March 10 practice
Total
Symptomatic
Asymptomatic
Total
Symptomatic
Asymptomatic
Attended
78
51 (65.4)
27 (34.6)
61
53§ (86.9)
8 (13.1)
Did not attend
40
4 (10.0)
36 (90.0)
61
3 (4.9)
58 (95.1)
Attendance information missing
4
1 (25.0)
3 (75.0)
0
0 (—)
0 (—)
Attended only one practice
21
1 (4.8)
20 (95.2)
3
2 (66.7)
1 (33.3)
Abbreviation: COVID-19 = coronavirus disease 2019.
*	No choir members were symptomatic at the March 3 practice.
†	Thirty-seven choir members attended neither practice; two developed symptoms, and 35 remained asymptomatic.
§	Includes index patient; if the index patient excluded, 52 secondary cases occurred among the other 60 attendees (attack rate = 86.7%).
FIGURE. Confirmed* and probable† cases of COVID-19 associated with two choir practices, by date of symptom onset (N = 53) — Skagit County, 
Washington, March 2020
0
2
4
6
8
10
12
14
16
18
20
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
No. of cases
Date of symptom onset
Choir 
practice
Choir 
practice
Index 
patient 
Probable
Confirmed
Abbreviation: COVID-19 = coronavirus disease 2019.
*	Positive reverse transcription–polymerase chain reaction test result.
†	Attendance at the March 10 practice and clinically compatible symptoms as defined by the Council of State and Territorial Epidemiologists, Interim-20-ID-01: 
Standardized surveillance case definition and national notification for 2019 novel coronavirus disease (COVID-19). https://cdn.ymaws.com/www.cste.org/resource/
resmgr/2020ps/interim-20-id-01_covid-19.pdf. 
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US Department of Health and Human Services/Centers for Disease Control and Prevention
TABLE 2. Signs and symptoms reported at the onset of COVID-19 illness and during the course of illness among persons infected at a choir 
practice (N = 53)* — Skagit County, Washington, March 2020
Sign or symptom
No. (%)
no./No. (%)
Reported at onset of illness
Reported during course of illness
All cases
(N = 53)
Confirmed cases
(N = 33)
All cases
(N = 53)
Confirmed cases
(N = 33)
Cough
27 (50.9)
18 (54.5)
47/53 (88.7)
30/33 (90.9)
Fever
28 (52.8)
15 (45.5)
36/53 (67.9)
25/33 (75.8)
Myalgia
13 (24.5)
9 (27.3)
34/52 (65.4)
24/32 (75.0)
Headache
10 (18.9)
7 (21.2)
32/53 (60.4)
20/33 (60.6)
Chills or rigors
7 (13.2)
6 (18.2)
23/51 (45.1)
16/31 (51.6)
Congestion
4 (7.5)
2 (6.1)
25/52 (48.1)
15/32 (46.9)
Pharyngitis
2 (3.8)
2 (6.1)
12/52 (23.1)
8/32 (25.0)
Lethargy
4 (7.5)
2 (6.1)
5/52 (9.6)
3/32 (9.4)
Fatigue
3 (5.7)
1 (3.0)
24/52 (46.2)
15/32 (46.9)
Aguesia (loss of taste)
1 (1.9)
1 (3.0)
11/48 (22.9)
5/28 (17.9)
Anosmia (loss of smell)
1 (1.9)
1 (3.0)
10/48 (20.8)
5/28 (17.9)
Chest congestion or tightness
1 (1.9)
1 (3.0)
5/52 (9.6)
4/32 (12.5)
Weakness
1 (1.9)
1 (3.0)
3/52 (5.8)
2/32 (6.3)
Eye ache
1 (1.9)
1 (3.0)
1/52 (1.9)
1/32 (3.1)
Dyspnea
0 (—)
0 (—)
8/51 (15.7)
8/31 (25.8)
Diarrhea
0 (—)
0 (—)
8/52 (15.4)
6/32 (18.8)
Pneumonia
0 (—)
0 (—)
6/53 (11.3)
6/33 (18.2)
Nausea
0 (—)
0 (—)
3/52 (5.8)
3/32 (9.4)
Acute hypoxemic respiratory failure
0 (—)
0 (—)
3/53 (5.7)
3/33 (9.1)
Abdominal pain or cramps
0 (—)
0 (—)
2/52 (3.8)
2/32 (6.3)
Malaise
1 (1.9)
0 (—)
1/52 (1.9)
0/32 (—)
Anorexia
0 (—)
0 (—)
1/52 (1.9)
0/32 (—)
Vomiting
0 (—)
0 (—)
0/52 (—)
0/32 (—)
Abbreviation: COVID-19 = coronavirus disease 19.
*	Including the index patient.
and March 10 practices and thus could have been infected 
earlier and might have been infectious in the 2 days preceding 
symptom onset (i.e., as early as March 9). The attack rate in 
this group (53.3% and 86.7% among confirmed cases and all 
cases, respectively) was higher than that seen in other clusters, 
and the March 10 practice could be considered a superspread­
ing event (3,4). The median incubation period of COVID-19 
is estimated to be 5.1 days (8). The median interval from 
exposure during the March 10 practice to onset of illness was 
3 days, indicating a more rapid onset.
Choir practice attendees had multiple opportunities for 
droplet transmission from close contact or fomite transmis­
sion (9), and the act of singing itself might have contributed 
to SARS-CoV-2 transmission. Aerosol emission during speech 
has been correlated with loudness of vocalization, and certain 
persons, who release an order of magnitude more particles 
than their peers, have been referred to as superemitters and 
have been hypothesized to contribute to superspeading 
events (1). Members had an intense and prolonged exposure, 
singing while sitting 6–10 inches from one another, possibly 
emitting aerosols.
The findings in this report are subject to at least two limi­
tations. First, the seating chart was not reported because of 
concerns about patient privacy. However, with attack rates of 
53.3% and 86.7% among confirmed and all cases, respectively, 
and one hour of the practice occurring outside of the seating 
arrangement, the seating chart does not add substantive addi­
tional information. Second, the 19 choir members classified 
as having probable cases did not seek testing to confirm their 
illness. One person classified as having probable COVID-19 
did seek testing 10 days after symptom onset and received a 
negative test result. It is possible that persons designated as 
having probable cases had another illness.
This outbreak of COVID-19 with a high secondary attack 
rate indicates that SARS-CoV-2 might be highly transmis­
sible in certain settings, including group singing events. This 
underscores the importance of physical distancing, including 
maintaining at least 6 feet between persons, avoiding group 
gatherings and crowded places, and wearing cloth face cover­
ings in public settings where other social distancing measures 
are difficult to maintain during this pandemic. The choir miti­
gated further spread by quickly communicating to its members 
and notifying SCPH of a cluster of cases on March 18. When 
first contacted by SCPH during March 18–20, nearly all 
persons who attended the practice reported they were already 
self-isolating or quarantining. Current CDC recommenda­
tions, including maintaining physical distancing of at least 
6 feet and wearing cloth face coverings if this is not feasible, 
washing hands often, covering coughs and sneezes, staying 
home when ill, and frequently cleaning and disinfecting 
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high-touch surfaces, remain critical to reducing transmission. 
Additional information is available at https://www.cdc.gov/
coronavirus/2019-ncov/prevent-getting-sick/prevention.html.
Acknowledgments
Patients described in this report; health care personnel who cared 
for them; Skagit County Public Health staff members and leaders, 
particularly the Communicable Disease investigators; Washington 
State Department of Health.
Corresponding author: Lea Hamner, leah@co.skagit.wa.us, 360-416-1500.
	 1Skagit County Public Health, Mount Vernon, Washington.
All authors have completed and submitted the International 
Committee of Medical Journal Editors form for disclosure of 
potential conflicts of interest. All authors report receipt of funding 
through Public Health Emergency Preparedness grant from the 
Washington State Department of Health during the conduct of the 
study. No other potential conflicts of interest were disclosed.
References
1.	Asadi S, Wexler AS, Cappa CD, Barreda S, Bouvier NM, Ristenpart WD. 
Aerosol emission and superemission during human speech increase 
with voice loudness. Sci Rep 2019;9:2348. https://doi.org/10.1038/
s41598-019-38808-z
2.	Wang D, Hu B, Hu C, et al. Clinical characteristics of 138 hospitalized patients 
with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA 
2020;323:1061–9. https://doi.org/10.1001/jama.2020.1585
3.	McMichael TM, Currie DW, Clark S, et al. Epidemiology of COVID-19 
in a long-term care facility in King County, Washington. N Engl J Med 
2020;NEJMoa2005412. https://doi.org/10.1056/NEJMoa2005412
4.	Ghinai I, Woods S, Ritger KA, et al. Community transmission of 
SARS-CoV-2 at two family gatherings—Chicago, Illinois, February–
March 2020. MMWR Morb Mortal Wkly Rep 2020;69:446–50. https://
doi.org/10.15585/mmwr.mm6915e1
5.	South Korean city on high alert as coronavirus cases soar at ‘cult’ church. 
The Guardian, US Edition. February 20, 2020. https://www.theguardian.
com/world/2020/feb/20/south-korean-city-daegu-lockdown-coronavirus-
outbreak-cases-soar-at-church-cult-cluster
6.	Council of State and Territorial Epidemiologists. Interim-20-ID-01: 
standardized surveillance case definition and national notification for 
2019 novel coronavirus disease (COVID-19). Atlanta, GA: Council of 
State and Territorial Epidemiologists; 2020. https://cdn.ymaws.com/www.
cste.org/resource/resmgr/2020ps/interim-20-id-01_covid-19.pdf
7.	He X, Lau EHY, Wu P, et al. Temporal dynamics in viral shedding and 
transmissibility of COVID-19. Nat Med 2020;26:672–5.
8.	Lauer SA, Grantz KH, Bi Q, et al. The incubation period of coronavirus 
disease 2019 (COVID-19) from publicly reported confirmed cases: 
estimation and application. Ann Intern Med 2020;172:577. https://doi.
org/10.7326/M20-0504
9.	van Doremalen N, Bushmaker T, Morris DH, et al. Aerosol and surface 
stability of SARS-CoV-2 as compared with SARS-CoV-1. N Engl J Med 
2020;382:1564–7. https://doi.org/10.1056/NEJMc2004973
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Exhibit B 
 
 
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Morbidity and Mortality Weekly Report 
632	
MMWR  /  May 22, 2020  /  Vol. 69  /  No. 20
US Department of Health and Human Services/Centers for Disease Control and Prevention
High COVID-19 Attack Rate Among Attendees at Events at a Church — 
Arkansas, March 2020
Allison James, DVM, PhD1,2; Lesli Eagle1; Cassandra Phillips1; D. Stephen Hedges, MPH1; Cathie Bodenhamer1; Robin Brown, MPAS, MPH1; 
J. Gary Wheeler, MD1; Hannah Kirking, MD3
On May 19, 2020, this report was posted as an MMWR Early 
Release on the MMWR website (https://www.cdc.gov/mmwr).
On March 16, 2020, the day that national social distancing 
guidelines were released (1), the Arkansas Department of Health 
(ADH) was notified of two cases of coronavirus disease 2019 
(COVID-19) from a rural county of approximately 25,000 
persons; these cases were the first identified in this county. The 
two cases occurred in a husband and wife; the husband is the 
pastor at a local church (church A). The couple (the index cases) 
attended church-related events during March 6–8, and devel­
oped nonspecific respiratory symptoms and fever on March 10 
(wife) and 11 (husband). Before his symptoms had developed, 
the husband attended a Bible study group on March 11. 
Including the index cases, 35 confirmed COVID-19 cases 
occurred among 92 (38%) persons who attended events held 
at church A during March 6–11; three patients died. The age-
specific attack rates among persons aged ≤18 years, 19–64 years, 
and ≥65 years were 6.3%, 59.4%, and 50.0%, respectively. 
During contact tracing, at least 26 additional persons with 
confirmed COVID-19 cases were identified among community 
members who reported contact with church A attendees and 
likely were infected by them; one of the additional persons was 
hospitalized and subsequently died. This outbreak highlights 
the potential for widespread transmission of SARS-CoV-2, the 
virus that causes COVID-19, both at group gatherings during 
church events and within the broader community. These find­
ings underscore the opportunity for faith-based organizations 
to prevent COVID-19 by following local authorities’ guidance 
and the U.S. Government’s Guidelines: Opening Up America 
Again (2) regarding modification of activities to prevent virus 
transmission during the COVID-19 pandemic.
On March 10 and 11, the wife of the church pastor, aged 
56 years, and the pastor, aged 57 years, developed fever and 
cough. On March 12, the pastor, after becoming aware of similar 
nonspecific respiratory symptoms among members of their con­
gregation, closed church A indefinitely. Because of fever, cough, 
and increasing shortness of breath, the couple sought testing 
for SARS-CoV-2 on March 13; both were notified of positive 
results by reverse transcription–polymerase chain reaction test­
ing on March 16. The same day, ADH staff members began an 
investigation to identify how the couple had been exposed and 
to trace persons with whom they had been in contact. Based 
on their activities and onset dates, they likely were infected at 
church A events during March 6–8, and the husband might 
have then exposed others while presymptomatic during a Bible 
study event held on March 11.
During March and April 2020, all persons in Arkansas 
who received testing for SARS-CoV-2 at any laboratory were 
entered into a database (Research Electronic Data Capture 
[REDCap]; version 8.8.0; Vanderbilt University) managed by 
ADH. Using a standardized questionnaire, ADH staff members 
interviewed persons who had positive test results to ascertain 
symptoms, onset date, and potential exposure information, 
including epidemiologic linkages to other COVID-19 patients; 
this information was stored in the database. Close contacts of 
patients with laboratory-confirmed cases of COVID-19 were 
interviewed and enrolled in active symptom monitoring; those 
who developed symptoms were tested and their information 
was also entered into the database. Church A–associated cases 
were defined as those in 1) persons who had laboratory results 
positive for SARS-CoV-2 who identified contact with church A 
attendees as a source of exposure and 2) actively monitored 
contacts of church attendees who had a test result positive for 
SARS-CoV-2 after becoming symptomatic.
The public health investigation focused on the transmission 
of SARS-CoV-2 among persons who attended church A events 
during March 6–11. To facilitate the investigation, the pastor 
and his wife generated a list of 94 church members and guests 
who had registered for, or who, based on the couple’s recollec­
tion, might have attended these events.
During March 6–8, church A hosted a 3-day children’s 
event which consisted of two separate 1.5-hour indoor ses­
sions (one on March 6 and one on March 7) and two, 1-hour 
indoor sessions during normal church services on March 8. 
This event was led by two guests from another state. During 
each session, children participated in competitions to collect 
offerings by hand from adults, resulting in brief close contact 
among nearly all children and attending adults. On March 7, 
food prepared by church members was served buffet-style. 
A separate Bible study event was held March 11; the pastor 
reported most attendees sat apart from one another in a large 
room at this event. Most children and some adults participated 
in singing during the children’s event; no singing occurred 
during the March 11 Bible study. Among all 94 persons who 
might have attended any of the events, 19 (20%) attended 
both the children’s event and Bible study.
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Morbidity and Mortality Weekly Report
MMWR  /  May 22, 2020  /  Vol. 69  /  No. 20	
633
US Department of Health and Human Services/Centers for Disease Control and Prevention
Summary
What is already known about this topic?
Large gatherings pose a risk for SARS-CoV-2 transmission.
What is added by this report?
Among 92 attendees at a rural Arkansas church during 
March 6–11, 35 (38%) developed laboratory-confirmed 
COVID-19, and three persons died. Highest attack rates were 
in persons aged 19–64 years (59%) and ≥65 years (50%). An 
additional 26 cases linked to the church occurred in the 
community, including one death.
What are the implications for public health practice?
Faith-based organizations should work with local health officials 
to determine how to implement the U.S. Government guide­
lines for modifying activities during the COVID-19 pandemic to 
prevent transmission of the virus to their members and 
their communities.
The husband and wife were the first to be recognized by 
ADH among the 35 patients with laboratory-confirmed 
COVID-19 associated with church A attendance identified 
through April 22; their illnesses represent the index cases. 
During the investigation, two persons who were symptomatic 
(not the husband and wife) during March 6–8 were identi­
fied; these are considered the primary cases because they likely 
initiated the chain of transmission among church attendees. 
Additional cases included those in persons who attended any 
church A events during March 6–11, but whose symptom 
onset occurred on or after March 8, which was 2 days after 
the earliest possible church A exposure. One asymptomatic 
attendee who sought testing after household members became 
ill was included among these additional cases.
Consistent with CDC recommendations for laboratory test­
ing at that time (3), clinical criteria for testing included cough, 
fever, or shortness of breath; asymptomatic persons were not 
routinely tested. To account for this limitation when calculating 
attack rates, upper and lower boundaries for the attack rates 
were estimated by dividing the total number of persons with 
laboratory-confirmed COVID-19 by the number of persons 
tested for SARS-CoV-2 and by the number of persons who 
attended church A during March 6–11, respectively. All analy­
ses were performed using R statistical software (version 4.0.0; 
The R Foundation). Risk ratios were calculated to compare 
attack rates by age, sex, and attendance dates. Fisher’s exact 
test was used to calculate two-sided p-values; p-values <0.05 
were considered statistically significant.
Overall, 94 persons attended church A events during 
March 6–11 and might have been exposed to the index patients 
or to another infectious patient at the same event; among these 
persons, 92 were successfully contacted and are included in 
the analysis. Similar proportions of church A attendees were 
aged ≤18 years (35%), 19–64 years (35%), and ≥65 years 
(30%) (Table 1). However, a higher proportion of adults 
aged 19–64 years and ≥65 years were tested (72% and 50%, 
respectively), and received positive test results (59% and 50%), 
than did younger persons. Forty-five persons were tested for 
SARS-CoV-2, among whom 35 (77.8%) received positive test 
results (Table 2).
During the investigation, two church A participants who 
attended the March 6–8 children’s event were found to have 
had onset of symptoms on March 6 and 7; these represent 
the primary cases and likely were the source of infection of 
other church A attendees (Figure). The two out-of-state guests 
developed respiratory symptoms during March 9–10 and 
later received diagnoses of laboratory-confirmed COVID-19, 
suggesting that exposure to the primary cases resulted in their 
infections. The two primary cases were not linked except 
through the church; the persons lived locally and reported no 
travel and had no known contact with a traveler or anyone 
with confirmed COVID-19. Patient interviews revealed no 
additional common exposures among church attendees.
The estimated attack rate ranged from 38% (35 cases among 
all 92 church A event attendees) to 78% (35 cases among 45 
church A event attendees who were tested for SARS-CoV-2). 
When stratified by age, attack rates were significantly lower 
among persons aged ≤18 years (6.3%–25.0%) than among 
adults aged 19–64 years (59.4%–82.6%) (p<0.01). The risk 
ratios for persons aged ≤18 years compared with those for 
persons aged 19–64 years were 0.1–0.3. No severe illnesses 
occurred in children. Among the 35 persons with laboratory-
confirmed COVID-19, seven (20%) were hospitalized; three 
(9%) patients died.
At least 26 additional confirmed COVID-19 cases were 
identified among community members who, during contact 
tracing, reported contact with one or more of the 35 church A 
members with COVID-19 as an exposure. These persons 
likely were infected by church A attendees. Among these 26 
persons, one was hospitalized and subsequently died. Thus, 
as of April 22, 61 confirmed cases (including eight [13%] 
hospitalizations and four [7%] deaths) had been identified in 
persons directly and indirectly associated with church A events.
Discussion
This investigation identified 35 confirmed COVID-19 cases 
among 92 attendees at church A events during March 6–11; 
estimated attack rates ranged from 38% to 78%. Despite 
canceling in-person church activities and closing the church 
as soon as it was recognized that several members of the con­
gregation had become ill, widespread transmission within 
church A and within the surrounding community occurred. 
The primary patients had no known COVID-19 exposures in 
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Morbidity and Mortality Weekly Report 
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MMWR  /  May 22, 2020  /  Vol. 69  /  No. 20
US Department of Health and Human Services/Centers for Disease Control and Prevention
TABLE 1. Demographic characteristics, church A event attendance, and SARS-CoV-2 testing status of persons who attended church A events 
where persons with confirmed COVID-19 (N = 92) also attended — Arkansas, March 2020
Characteristic
All attendees
No. (%)*
No. (%) 
tested†
p-value§
No. (%) 
who tested positive†
p-value§
Total
92 (100)
45 (49)
—
35 (38)
—
Age group (yrs)
≤18
32 (35)
8 (25)
0.001
2 (6)
0.004
18–64
32 (35)
23 (72)
19 (59)
≥65
28 (30)
14 (50)
14 (50)
Sex
Male
44 (48)
22 (50)
1.0
17 (39)
1.0
Female
48 (52)
23 (48)
18 (38)
Church A event attendance
Weekend only (Mar 6–8)
64 (70)
33 (52)
0.28
28 (44)
0.16
Bible study only (Mar 11)
9 (10)
2 (22)
1 (11)
Both weekend and Bible study
19 (21)
10 (53)
6 (32)
Abbreviation: COVID-19 = coronavirus disease 2019.
*	Includes all persons who were confirmed to have attended church A events during March 6–11; percentages are column percentages.
†	Percentage of attendees (row percentages).
§	Calculated with Fisher’s exact test.
TABLE 2. Estimated attack rates of COVID-19 among attendees at church A events — Arkansas, March 6–11, 2020
Characteristic
All Mar 6–11 church A attendees
(lower bound)
All tested Mar 6–11 church A attendees
(upper bound)
No. of cases/no. exposed (%)
Risk ratio (95% CI)
p-value
No. of cases/no. tested (%)
Risk ratio (95% CI)
p-value
Overall
35/92 (38.0)
—
—
35/45 (77.8)
—
—
Age group (yrs)
≤18
2/32 (6.3)
0.1 (0.03–0.4)
<0.001
2/8 (25.0)
0.3 (0.1–1.0)
0.003
19–64
19/32 (59.4)
Referent
—
19/23 (82.6)
Referent
—
≥65
14/28 (50.0)
0.8 (0.5–1.3)
0.47
14/14 (100.0)
1.2 (1.0–1.5)
0.10
Sex
Male
17/44 (38.6)
1.0 (0.6–1.7)
0.91
17/22 (77.3)
1.0 (0.7–1.3)
0.94
Female
18/48 (37.5)
Referent
—
18/23 (78.3)
Referent
—
Church A event attendance
Weekend only (Mar 6–8)
28/64 (43.8)
1.4 (0.7–2.8)
0.3
28/33 (84.8)
1.4 (0.8–2.4)
0.09
Bible study only (Mar 11)
1/9 (11.1)
0.4 (0.05–2.5)
0.25
1/2 (50.0)
1.7 (0.4–6.8)
0.21
Both weekend and Bible study
6/19 (31.6)
Referent
—
6/10 (60.0)
Referent
—
Abbreviations: CI = confidence interval; COVID-19 = coronavirus disease 2019.
the 14 days preceding their symptom onset dates, suggesting 
that local transmission was occurring before case detection.
Children represented 35% of all church A attendees but 
accounted for only 18% of persons who received testing and 
6% of confirmed cases. These findings are consistent with 
those from other reports suggesting that many children with 
COVID-19 experience more asymptomatic infections or 
milder symptoms and have lower hospitalization rates than do 
adults (4,5). The role of asymptomatic or mildly symptomatic 
children in SARS-CoV-2 transmission remains unknown and 
represents a critical knowledge gap as officials consider reopen­
ing public places.
The risk for symptomatic infection among adults aged 
≥65 years was not higher than that among adults aged 
19–64 years. However, six of the seven hospitalized persons 
and all three deaths occurred in persons aged ≥65 years, 
consistent with other U.S. data indicating a higher risk for 
COVID-19–associated hospitalization and death among per­
sons aged ≥65 years (6).
The findings in this report are subject to at least four limi­
tations. First, some infected persons might have been missed 
because they did not seek testing, were ineligible for testing 
based on criteria at the time, or were unable to access testing. 
Second, although no previous cases had been reported from 
this county, undetected low-level community transmission 
was likely, and some patients in this cluster might have had 
exposures outside the church. Third, risk of exposure likely 
varied among attendees but could not be characterized because 
data regarding individual behaviors (e.g., shaking hands or 
hugging) were not collected. Finally, the number of cases 
beyond the cohort of church attendees likely is undercounted 
because tracking out-of-state transmission was not possible, 
and patients might not have identified church members as 
their source of exposure.
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Morbidity and Mortality Weekly Report
MMWR  /  May 22, 2020  /  Vol. 69  /  No. 20	
635
US Department of Health and Human Services/Centers for Disease Control and Prevention
FIGURE. Date of symptom onset* among persons with laboratory-confirmed cases of COVID-19 (N = 35) who attended March 6–11 church A 
events — Arkansas, March 6–23, 2020
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
0
1
2
3
4
5
6
7
8
9
10
No. of cases
Date of symptom onset, March 2020
Children’s event and 
Sunday service
Symptom onset, 
primary cases
Symptom onset, 
index cases
Church A 
closed
Bible 
study 
Abbreviation: COVID-19 = coronavirus disease 2019.
*	One asymptomatic person who had a positive test result is included on the date of specimen collection (March 18).
High transmission rates of SARS-CoV-2 have been reported 
from hospitals (7), long-term care facilities (8), family gath­
erings (9), a choir practice (10), and, in this report, church 
events. Faith-based organizations that are operating or planning 
to resume in-person operations, including regular services, 
funerals, or other events, should be aware of the potential for 
high rates of transmission of SARS-CoV-2. These organizations 
should work with local health officials to determine how to 
implement the U.S. Government’s guidelines for modifying 
activities during the COVID-19 pandemic to prevent transmis­
sion of the virus to their members and their communities (2).
Acknowledgments
Members of the congregation of church A, including the pastor and 
his wife; Arkansas Department of Health; Suzanne Beavers, CDC; 
Laura Rothfeldt, Arkansas Department of Health; state and local 
health departments where out-of-state visitors resided.
Corresponding author: Allison E. James, hwj7@cdc.gov, 501-614-5278.
	 1Arkansas Department of Health; 2Epidemic Intelligence Service, CDC; 
3COVID-19 Response Team, CDC.
All authors have completed and submitted the International 
Committee of Medical Journal Editors form for disclosure of potential 
conflicts of interest. No potential conflicts of interest were disclosed.
References
	 1.	Office of the President of the United States. Coronavirus guidelines for 
America. Washington, DC: Office of the President of the United States; 
2020. https://www.whitehouse.gov/briefings-statements/coronavirus-
guidelines-america/
	 2.	Office of the President of the United States. Guidelines: opening 
up America again. Washington, DC: Office of the President of the 
United States; 2020. https://www.whitehouse.gov/openingamerica/
	 3.	CDC. Health Alert Network: update and interim guidance on outbreak 
of coronavirus disease 2019 (COVID-19). Atlanta, GA: US Department 
of Health and Human Services, CDC; 2020. https://emergency.cdc.gov/
han/2020/HAN00428.asp
	 4.	Bialek S, Gierke R, Hughes M, McNamara LA, Pilishvili T, Skoff T; CDC 
COVID-19 Response Team. Coronavirus disease 2019 in children—
United States, February 12–April 2, 2020. MMWR Morb Mortal Wkly 
Rep 2020;69:422–6. https://doi.org/10.15585/mmwr.mm6914e4
	 5.	Dong Y, Mo X, Hu Y, et al. Epidemiology of COVID-19 among 
children in China. Pediatrics 2020. Epub March 16, 2020. https://doi.
org/10.1542/peds.2020-0702
	 6.	Bialek S, Boundy E, Bowen V, et al.; CDC COVID-19 Response 
Team. Severe outcomes among patients with coronavirus disease 2019 
(COVID-19)—United States, February 12–March 16, 2020. MMWR 
Morb Mortal Wkly Rep 2020;69:343–6. https://doi.org/10.15585/
mmwr.mm6912e2
	 7.	Heinzerling A, Stuckey MJ, Scheuer T, et al. Transmission of COVID-19 
to health care personnel during exposures to a hospitalized patient—
Solano County, California, February 2020. MMWR Morb Mortal Wkly 
Rep 2020;69:472–6. https://doi.org/10.15585/mmwr.mm6915e5
	 8.	McMichael TM, Currie DW, Clark S, et al. Epidemiology of Covid-19 
in a long-term care facility in King County, Washington. N Engl J Med 
2020. Epub March 27, 2020. https://doi.org/10.1056/NEJMoa2005412
	 9.	Ghinai I, Woods S, Ritger KA, et al. Community transmission of SARS-
CoV-2 at two family gatherings—Chicago, Illinois, February–March 
2020. MMWR Morb Mortal Wkly Rep 2020;69:446–50. https://doi.
org/10.15585/mmwr.mm6915e1
	10.	Hamner L, Dubbel P, Capron I, et al. High SARS-CoV-2 attack rate 
following exposure at a choir practice—Skagit County, Washington, 
March 2020. MMWR Morb Mortal Wkly Rep 2020;69:606–10. https://
doi.org/10.15585/mmwr.mm6919e6
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