A confluence of potential events in the coming weeks and months could exacerbate the spread of coronavirus infections following the summer surge, public health experts warn. 

Some football programs might allow thousands of fans to attend games in massive stadiums. In Washington, D.C., people from across the country will likely attend a demonstration commemorating the original March on Washington and cap off a summer of protests for racial justice.

And while the presidential nominating conventions will be mostly remote, many smaller political events are poised to occur and many people will likely be voting in person. 

Perhaps most significantly, millions of students, teachers and staff could soon be back in classrooms. Some have already arrived, with new infections popping up almost immediately. 

America’s leaders are pushing to get the country back to normal after months of lockdowns and economic disruption caused by the COVID-19 pandemic. 

But if all of those things happen at once, with many states unable to bring down COVID-19 infection rates to manageable levels, experts fear that the dire situation in the United States can only get worse. 

“This is not going to be a linear explosion of disease,” said American Public Health Association Executive Director Georges Benjamin. “It will be exponential.” 

“People need to be aware that all of these effects are cumulative: that when you have schools open, and universities open, and people going to these events, and at the same time still have indoor bars and restaurants open, too, that we are going to see a surge in cases, and I think we as a society have to make a decision about our priorities,” said former Baltimore Health Commissioner Leana Wen, a George Washington University public health professor. 

It’s not necessarily too late for certain mass gatherings to happen safely, public health experts say. They acknowledge that leaders, and society as a whole, are eager to get back in operation after half a year of life interrupted. 

One thing that would help, they say, is stronger national leadership guiding what is appropriate to reopen and when. Some note that the administration’s own reopening guidelines, issued by the Centers for Disease Control and Prevention back in May, provide a good roadmap for how to do it — if only they would be followed. 

Cyrus Shahpar, director of a team focused on epidemic prevention at Resolve to Save Lives, a nonprofit focused on global health, said if leaders are intent on letting mass gatherings occur, he hopes they will learn from experiences and potential mistakes. 

“You’re going to see a natural experiment over the next few weeks,” he said. 

‘Should be the last to come back’

Public health experts interviewed by CQ Roll Call didn’t express concern over any one single event or phase of reopening, but emphasized that the state of the outbreak in much of the U.S. makes it risky for any kind of school reopening or mass gathering to occur — much less all of them. 

There is a consensus that reopening schools is a top priority and, in some places, the benefits may outweigh the risks, especially for younger children. But communities attempting that should have low infection rates. 

“If there are states where the background transmission is low and declining and deaths are declining, and then there is very careful planning and all stakeholders have committed to going forward, it’s possible, if done with great care and caution,” said Howard Koh, a professor at the Harvard T.H. Chan School of Public Health and a former Health and Human Services official during the Obama administration. 

If the infection rate is too high, states should pause things like indoor dining, church services and other gatherings that are driving community spread of the virus that causes COVID-19. Officials also need better information about their local situations. 

“Right now, people are having a massive debate about whether or not to open schools and they don’t have a sense of what the disease prevalence is in their community and why those decisions are being made,” said Benjamin, of the American Public Health Association. 

Communities that want to stage mass gatherings or reopen parts of society will also need plans in place for when new infections inevitably occur, Koh added. 

“At any point for reopening or starting in on these activities, there has to be planning ahead of time. What happens if there are cases and there is a need to shut it all down again? What would be the triggers to stop?” Koh said. 

Much of that will hinge on having COVID-19 tests that can be processed quickly. Short of having adequate testing infrastructure, it would likely be necessary to halt indoor activities and large gatherings. 

There is also a distinction between indoor and outdoor gatherings, with transmission less likely in outdoor settings. But that doesn’t mean the outdoor environments are risk-free. The threat increases when you add more people and public health interventions like mask wearing and social distancing aren’t followed. 

That’s why thousands of people convening in a football stadium or for a political rally can still be concerning. 

The University of Texas, for example, is for now planning to allow 50 percent capacity for Longhorn football games, in a stadium that holds up to 100,000 fans. The university’s athletic department insists that fans will keep a proper distance and will have to wear masks. 

In recent days, more questions have emerged about whether college football will be played at all, much less with fans. But while several major conferences seem poised to cancel their seasons, Texas and others in the Southeastern Conference seem more likely to move ahead.

“We’re constantly monitoring and reviewing various stadium models,” John Bianco, a spokesman for the University of Texas athletic department, said. Chris Del Conte, the school’s athletic director, recently said in an online post that officials are considering 25 percent attendance levels.  

But it could still be difficult to control that environment. The leader of Austin’s health department said the plan was “not really living in the realm of reality,” according to local news outlet KXAN.   

“You still have people congregating while they are waiting in line, buying tickets, in public restrooms,” said Wen. “We know that these types of mass gatherings should be the last to come back.”

Wen also noted that people may come from far and wide to attend something like a football game, making it easier for infection to spread from one community to another.  

At a commemoration of the original March on Washington planned at the end of August, there could be a similar dynamic, with people coming into Washington from many different states. The organizers, including Rev. Al Sharpton’s National Action Network, have a permit for 100,000 participants on the National Mall, but don’t have projections for how many will attend, they told CQ Roll Call.  

Earlier protests in cities all over the country sparked by the murders of Black Americans by police weren’t seen as major drivers of viral transmission. While it’s likely that there was some transmission from these events, said Benjamin, they were happening at a time when many bars, restaurants and other indoor spaces were also reopening, making it hard to determine how infection was spreading. 

But the June protests were happening all across the country, meaning people didn’t have to travel far to attend one. The August march in Washington could bring people from all over, and the organizers are arranging buses to bring them to Washington. As of now, that includes states that the District has put under a two-week quarantine order, but the organizers appear to be seeking to keep attendees safe. 

In response to questions from CQ Roll Call, NAN said buses will only be allowed to come from states D.C. officials consider safe. People in states under the quarantine restrictions will be asked to march locally on their senators’ offices and NAN will provide large outdoor screens to view the Washington event. Buses traveling to Washington will be at half capacity, with one person per row. Volunteers will act as “security marshals” to enforce mask and social distancing guidelines. 

D.C. Mayor Muriel Bowser expressed optimism about the event’s safety. 

“It sounds like the organizers are trying to keep a mass gathering safe, so I think that is encouraging news,” she said at a July 31 press conference. “I will certainly consider what the health metrics suggest closer to that time.” 

Spread at schools

In-person attendance at schools will also likely result in cases spiking, with older students and adult staff members at higher risk of transmitting the virus and having COVID-19 symptoms. News reports from Israel document an explosion of new infections when schools reopened in May.

In states that have already seen children return to school, like Indiana, public health officials identified infected students almost immediately. A photo from a Georgia high school, shared widely online, showed that officials may not be enforcing social distancing and mask wearing in schools, despite the attendance of hundreds or thousands of students. 

Even if younger children are at lower risk of transmitting the virus or having bad symptoms — an assertion frequently made by President Donald Trump — a low-risk group so large will still result in a dramatic number of cases, Wen notes. 

“There is conflicting evidence about children and the spread of this disease,” she said. “Even if they spread it half as much as adults, half of a lot is a lot.” 

Some experts say that gatherings that are being planned at the moment won’t happen if current transmission levels don’t decrease or get worse and organizers realize that they must cancel or close right after opening.

A Georgia summer camp in June had to close just days after a counselor got sick, even though everyone at the camp had tested negative in the days before arriving, according to a recent CDC report. Hundreds of campers and staff were subsequently infected. Of those who later got tested, 76 percent of them tested positive. 

“It’s easy to say you’re going to open things, and they’ll open,” said Shahpar. “And they’ll close soon after, and I think we’re going to see that with some schools in some high-transmission areas soon.”