The U.S. Response: Too Little, Too Late

The U.S. Response:

Too Little, Too Late

Mary C. Vrtis, Ph.D., MSN, RN, OCN, NEA-BC, FCN

October 27, 2023

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Introduction

This chapter may be upsetting to some because we will discuss how things went wrong in the United States. If we do not look critically at what happened this time, then we are destined to repeat it. The death and long-term disability that has resulted from this uncontrollable virus makes it clear that we need to present a timely and united response to pandemic risks in the future. We cannot do that effectively without differentiating between the actions that positively affected outcomes, those that were inappropriate but did not affect outcomes, and those actions that negatively affected outcomes.

This is a factual account that describes a lot of bad actions and decisions. We do attribute responsibility to the decision makers that fueled the spread of COVID-19. However, it is VERY important to understand that no one person was responsible for what happened. It does not matter how much power that any single individual had at the time, or how bad a particular decision was, the death and destruction SARS-CoV-2 left in its wake could only have occurred if our systems of checks and balances failed.

As we will discuss in the chapter on pandemic preparation, the U.S. should have been able to face off with this virus as if it was a weapon of mass destruction launched by a foreign adversary. The systems were in place for the U.S. to take a leadership role in identifying and implementing solutions. Unfortunately, political decisions and infighting, conspiracy theories, and widespread anti-science mentality got in the way.

We can never do this again!

The U.S. Had a Disproportionate Number of COVID-19 Infections and Deaths

The United States has but 4.1% of the world population, however, 16.4% of those who died from COVID-19 were Americans. We also had 15.3% of worldwide COVID-19 infections, see figure 1 (secondary analysis CDC COVID-19 data tracker and current world population).

As evidenced by the outcomes and consequences of the COVID-19 pandemic, the U.S. response was too little and too late. Although highly qualified public health experts were providing clear and appropriate advice before SARS-CoV-2 reached the country, grandstanding politicians who knew nothing about controlling an infectious disease fought for media attention and sound bites. Conspiracy theorists were initiating wild and crazy disinformation and gullible people were amplifying the propaganda.

Nurses in leadership responsible for assuring care for the patients did not have enough staff, personal protective equipment, beds, life-saving medical devices, or hours in the day to address the demand.

Staff providing direct care were trying to learn about caring for patients with this previously unknown disease while getting infected themselves.

Nurses afraid of carrying the infection home were separated from and worried about their own families. Helping dying patients communicate electronically with their loved ones so that patients could say their goodbyes added to nurses’ worries about their own families. Patients with myocardial infarctions and other medical emergencies were lying on carts in emergency department hallways for days because there were no open beds. The bodies of those who died were stored in refrigerated trucks in many cities because there was no room to store them anywhere else.

Most times people were grateful for the care received, at other times COVID deniers and their family members were verbally, and at times even physically, abusive toward the staff trying to care for them.

Countless healthcare providers gave everything they had – some lost their health and well-being to long COVID, and almost six thousand (5,906) U.S. healthcare clinicians lost their lives.

This was a nightmare far beyond anything any of us could even have imagined in our tabletop disaster drills. For three years and seven months, healthcare providers at every level have battled SARS-CoV-2. This invisible enemy has caused great suffering and death for over one million, one hundred and thirty-six thousand, four hundred and seventy-three (1,136,473) Americans within the borders of this country. And unfortunately, it is not over.

Not one of these heroic nurses, therapists, nurses’ assistants, social workers, physicians, or supportive staff, has received any medals of honor, distinguished service crosses, silver, or bronze stars for their efforts. The battle continues to rage.

The normal method that many health care organizations used of “just in time ordering” of supplies did not work for personal protective equipment. Most organizations kept an adequate supply of one time use disposable protective equipment on hand for routine needs and then placed orders for more as the need developed.

Unfortunately, the supply chain was broken and there was no protective equipment to buy. Huge numbers of nurses and other healthcare workers had to provide direct care to patients with a potentially life-threatening disease without adequate protection. We discuss this issue in depth in the chapter A Global Shortage of Personal Protective Equipment.

As we will discuss in the chapter Pandemic Preparation, U.S., given the resources that have been committed to pandemic prevention over many years, and the number of governmental departments and divisions assigned to this goal, the U.S. should have been ready to stop the pandemic before it even reached our shores. Unfortunately, countless factors interfered.

We were not ready when COVID-19 hit us to implement a concerted effort to defeat this invisible enemy, and we are still not as ready as we need to be.

Deadly Delays: The U.S. Governmental Response

Unfortunately, in the most crucial early days of the COVID-19 pandemic, the response was completely inadequate. During the first year of pandemic, the U.S. Administration was ineffective and focused on political concerns instead of working with the scientists and public health officials who were thoroughly prepared to act.

White House briefings were filled with misinformation that contradicted and/ or misinterpreted what the medical experts presented. White House press briefings provided a platform for politicians to consume free airtime, while the infectious disease experts, like Dr. Anthony Fauci and Dr. Deborah Birx were silenced or excluded when they did not agree with the former president Trump.

The U.S. had very few cases in January and February of 2020, but this began to change in March of 2020. As shown in figure 3, the number of patients with COVID-19 in the U.S. rose very quickly. By April 10, 2020, the United States had more COVID-19 cases (over 500,000) and more COVID-19 deaths (over 30,000) than any other country in the world (COVID data tracker). All states were reporting high volumes of sick patients, but New York state was hit hardest with 159,937 patients (CDC 2023, March 15). Hospital nurses were immediately overwhelmed caring for severe and critically ill patients with COVID-19 infections, and the entire U.S. healthcare system was strained as very sick patients were being discharged to receive care in their homes or in skilled nursing facilities. Staff members were transferred to hospital units where they were needed most without time to orient and obtain specialty skills. Crisis standards of care were implemented.

Travel nurses were recruited to temporarily relocate to areas of highest need and received higher pay than their colleagues. Travel nurses received higher pay, but they also experienced higher risk as they specialized in caring for patients with COVID-19 infections, and sacrificed time with their own families to answer the call.

A Closer Look

In order to prevent a microbiological outbreak from becoming an epidemic, potential human hosts need to be protected from exposure to the infection. The quarantine time for SARS-CoV-2 has consistently been 10 days to 2 weeks. Self-quarantine by those who have an infection and those who have been exposed and may be developing an infection dramatically reduces transmission to others.

SARS-CoV-2 spread across the globe amazingly fast. The virus caused devastation everywhere. Asymptomatic transmission from people who were not aware that they were infected played a role in spreading this virus. However, it is the people who refused to demonstrate basic human concern for others that did the most damage.

Harm was done by people who did the following:

Refused to wear a mask when sick and/ or belittled those who did so to protect self and others.
Attacked public health officials, scientists, nurses, and other healthcare providers, verbally and/ or physically.
Promoted conspiracy theories that encouraged gullible people to act badly.
Filed lawsuits to stop mask and vaccine mandates.
Attended and/ or planned superspreader events.
Endorsed fake and/ or discredited “treatments” that could and did cause injuries.

Public Refusals to Follow Basic Infection Control Recommendations

A large proportion of the U.S. population refused to wear masks, to social distance, and to avoid crowds. This caused many superspreader events. Former president Trump was one of the loudest voices stating that recommendations for social distancing and mask wearing were not necessary. He personally refused to wear a mask.

The former president tested positive for SARS-CoV-2 and required hospitalization on October 2, 2020 (CDC, 2023, March 15). He wore a mask as he left the helicopter on return to the White House and then took it off to speak. He was visibly short of breath.

Members from both Houses of Congress were not able to reach across the great divide between political party lines to unite against the viral common enemy. The White House under the previous president was a source of disinformation and loyal followers of Trump refused to accept and apply the advice of public health experts.

Accurate expert advice from the country’s top infectious disease doctors, state and local health officials was not only ignored, but, as we will discuss later, these healthcare professionals were frequently threatened, bullied, and in some cases assaulted or physically attacked. It was not unusual for professionals to resign positions because they or their family members were threatened.

When experts who were educating the public contradicted the former president, many of his followers, including some in Congress, verbally attacked and demonized the infectious disease specialists. Conspiracy theories were rampant. Conspiracy theories and the anti-vaccination movement will be discussed further in separate chapters.

Politicians on the far right filed lawsuits to block short term lockdowns, vaccine, and mask mandates. At least 7 states filed lawsuits to end the federal travel mask mandates. Superspreader events where at least half of the politicians and participants refused to wear masks were scheduled at the White House on a regular basis.

True believers on the far right felt justified in ignoring the public health voices that were stressing that people stay six-foot apart and avoid crowds. The rights and safety of nurses and other healthcare clinicians caring for patients who had a highly contagious, potentially fatal disease were lost in noise and drama from grandstanding politicians. In hospitals and other healthcare settings, the situation went from bad to horrible. By the end of March 2020, some states had developed guidelines to exclude patients who were not likely to survive from use of ventilators and critical care beds.

Pandemic Prediction and Forecasting Science and Technology Working Group of the National Science and Technology Council (2016). Towards epidemic prediction: Federal efforts and opportunities in outbreak modeling.

Gerstein, D. M. (2020, May 5). “The federal research enterprise and COVID-19: A lesson in unpreparedness,” testimony presented to the House Science, Space, and Technology Committee on May 5, 2020, Homeland Security Operational Analysis Center operated by the RAND Corporation, CT-A360-1, 2020.

Nurses and Other Healthcare Professionals were NOT Protected!

Multiple surveys of RNs caring for patients with COVID-19 infections were conducted. Figure 5 shows that when results of 9 different surveys were combined that 54,269 of the 117,437 nurses surveyed (46.2%) did not have an adequate supply of N95 respirators to provide the first line of defense against SARS-CoV-2. Six of these surveys asked if RNs were required to reuse N95s. Reuse of single patient, one time use of N95 respirators continued as late as April 2022. A total of 99,429 of 133,495 (79.5%) of RNs surveyed were still required to reuse N95s (secondary analysis of results from Couper, et al., 2022, American Nurses Foundation, National Nurses United – see References Cited).

As of May 2021, the CDC provided new guidance and stated that the supply of NIOSH approved N95 respirators was adequate and that crisis capacity strategies were no longer needed. Healthcare facilities and organizations were instructed to discard previously used and/ or decontaminated respirators and to return to purchasing and using only NIOSH approved personal protective equipment (CDC, 2021. May).

The consequence of failure to protect nurses is that they were being infected by COVID-19 while providing care to their patients. As occurred during the first severe acute respiratory syndrome (SARS-CoV) outbreaks in 2003, 2004 and 2006, and the Middle Eastern respiratory syndrome (MERS-CoV) outbreaks in 2012 and 2015, large numbers of healthcare providers were infected by their patients. See chapter SARS and MERS: A Failure to Learn from Those Deadly Coronavirus Outbreaks. Nguyen, et al. (2020) collected responses from the COVID Symptom Study smartphone app starting the last week of March to April 23, 2020. Participants used the app voluntarily to self-report COVID-19 related information in real time. Responses from a total of 2,035,395 members of the general community were compared to those of 99,795 front line healthcare workers. Users were not included if they had used the app for less than 24 hours.

Figure 5 compares the number of confirmed COVID-19 infections per 100,000 for frontline healthcare workers in the U.K. and U.S. with the rates for the general public in each respective country.

The results make clear that frontline nurses and other healthcare workers were quite literally risking their own lives to care for infected patients.

Healthcare workers in the U.K. reported 2,905 testing confirmed infections per 100,000 app users, compared to 227 per 100,000 for the general public. In the U.S., healthcare users reported 1,836 infections per 100,000 users compared to 461 infections per 100,000 in general community users (Nguyen, et al., 2020).

The U.S. and the countries of the U.K. are high-income with advanced health care systems. These countries were not able to adequately assure the safety of nurses and other healthcare providers. Across the board, frontline healthcare workers reported inadequate personal protective equipment and/ or the need to reuse equipment designed for one-time, single patient use. More than a third of frontline workers reported not having the necessary protective equipment to stay safe.

The situation was worse for black and brown healthcare workers, see table 1:

Table 1

% of frontline workers who did not have or had to reuse PPE

Race	% without adequate PPE
White non-Hispanic¹	27.7%
Hispanic/ Latinx¹	49.6%
Black¹	33.5%
Asian¹	35.6%
More than 1 race¹	34.7%

^{1 Data from Nguyen, et al. (2020}

The authors also reported that Black, Asian, and healthcare workers of other ethnic minorities were at 1.8 times higher risk of developing a COVID-19 infection than non-Hispanic white workers (HR, hazard ratio 1.81, 95% CI 1.45-2.24). When compared to the general community, minority healthcare workers were 2.51 times more likely to develop a positive COVID-19 test (HR 2.51, 95% CI 2.18-2.89) (Nguyen, et al. 2020).

Please see the chapter on the Global Shortage of Personal Protective Equipment for further information.

Pre-pandemic Readiness

To be effective, mitigation measures for any type of infectious disease have to start immediately, while the infection is still contained to a limited area. Before the novel SARS-CoV-2 virus spread beyond the confines of the local area in China, a great deal of work had been done that ultimately helped, but the worldwide response was not enough to put a stop to the accelerated spread of this virus.

A new, deadly pneumonia was reported on December 31, 2019, and China had already identified the virus causing the severe acute respiratory syndrome as a Coronavirus and completed the genetic sequencing necessary to start work on diagnostic testing and vaccine development by January 12, 2020 (WHO, 2020, January 21). This information was shared with scientists all over the world via the GISAID database using tools originally designed to address flu pandemics. As we discuss in the chapter SARS and MERS: A Failure to Learn from Those Deadly Coronavirus Outbreaks, the U.S. should have been ready to prevent the deaths of almost 6,000 clinicians and 1.2 million Americans.

The United States has some of the most knowledgeable infectious disease specialists and medical research scientists in the world. The U.S. has a well-established, science driven, multi-layered public health network that includes federally funded, state and local programs, as well as public/ private partnerships with universities and philanthropic organization. There are also programs under the U.S. Department of Defense. U.S. scientists and medical experts regularly collaborate with global networks of similarly prepared experts to produce and publish research that ultimately translates into evidence-based guidelines for most medical and nursing specialties.

See the chapter Pre-COVID Pandemic Preparations, U.S. for additional information on the structure of federal government preparation for biological threats.

It was known since 2003 that Coronavirus mutations can be deadly, that these infections tend to be very contagious, and that healthcare workers became extremely ill and died from both SARS and MERS in all of the countries affected. The 2016 document Towards epidemic prediction: Federal efforts and opportunities in outbreak modeling, authored by the Pandemic Prediction and Forecasting Science and Technology Council, was published by the Obama Whitehouse.

What DID happen?

One way to evaluate the effectiveness of the efforts to control the spread of disease is to examine the outcome of mitigation efforts and to make comparisons between outcomes that result from multiple similar situations. We will compare and contrast U.S. outcomes for the Ebola crisis of 2014 with outcomes for COVID-19 in a separate chapter, A Comparison of Outcomes: the COVID-19 Pandemic and the U.S. Ebola Response 2014.

Another method of evaluating the effectiveness of mitigation efforts is to compare results for different countries. Unfortunately, this virus spread so quickly and so extensively, that there were no “best practices” to learn from.

We are going to do a deeper dive by comparing the U.S. and the U.K. as there are some marked differences in cumulative cases and deaths. The United Kingdom includes England, Wales, Scotland, and Northern Ireland. The U.K. countries and the U.S. are high income with advanced medical institutions. The U.K. has a national health service that provides care to all citizens.

Access to medical care in the U.S., is based on health insurance status. Despite the Affordable Care Act and expansion of Medicaid, there are still 27.6 million Americans who do not have health insurance. That is a decrease from the 48 million who were uninsured in 2010 (Cohen, et al., 2023; Finegold, et al., 2021), see figure 6. Many of the services needed for COVID-19 testing and vaccines was provided without charge. But care for comorbidities and prolonged post-infection needs were not without costs.

In the U.S., 56.3% of insurance is employee subsidized. Few people can afford to keep these policies after leaving a job if the employee becomes ill and is unable to work. Care needed for long COVID-19 and treatment of comorbidities that worsened during the infection was critical to survival. Nursing research that examines issues related to insurance status is needed.

To compare the situation in the two countries further, we used data from the World Health Organization Situation Reports. When the World Health Organization published Coronavirus disease 2019 (COVID-19) situation report 40 on February 29, 2020, the United Kingdom had 20 and the United States had 62 confirmed cases of SARS-CoV-2 infections (WHO, 2020, February 29), see table 2.

Table 2

A Comparison of Outcomes: Patients Infected and Deaths U.S. and U.K.

Date	WHO Sit Rep	U.K. Cases	U.K. Deaths	U.S. Cases	U.S. Deaths
Feb. 29, 2020	#40	20	0	62	0
Mar. 27, 2020	#67	11,662	578	68,334	991
April 24, 2020	#95	138,082	18,738	830,053	42,311
May 31, 2020	#132	272,830	38,376	1.7million	100,000

When the World Health Organization reported, on March 27, 2020, there had been 68,334 U.S. cases of confirmed infection with almost a thousand (991) deaths reported. The U.K. totals had risen to 11,662 cases with 578 deaths (WHO, 2020 March 27).

By the time that Coronavirus disease 2019 (COVID-19) situation report 95 was published on April 24, 2020, there were 138,082 cases and 18,738 deaths reported by the U.K. and 830,053 cases of infection and 42,311 deaths reported by the U.S. (WHO, 2020, April 24). As figure 7 illustrates, a month later, when the World Health Organization published Coronavirus disease (COVID-19) situation report 132 dated May 31, 2020, the U.S. had a cumulative of 1.7 million cases with over 100,000 dead, and the U.K. had 272,830 cases of infection with 38,376 deaths. The rapid rise in care needs was putting tremendous pressure on nurses and other healthcare workers who, as indicated above, were contracting COVID-19 at a much higher rate than the general population.

The steep climb evident in the graphs suggests that U.K. and U.S. nurses had very little time to adapt to the conditions that were placing them – and by extension their families – at high risk for contracting the infection.

As would be expected given that the U.S. is larger than the U.K., the number of deaths related to COVID-19 were quite a bit higher in the U.S. compared to the U.K. To make comparisons, using a death rate per 100,000 population, rather than a total number is helpful.

The U.S. had 331.45 million people (U.S. Census.gov) and the U.K. had 67.08 million (UK.gov) in 2020. To compare the situation in both locations during this time period, it was necessary to use death rates per 100,000 of the population and case fatality rates.

As shown in figure 8, at the end of April 2020, the U.S. COVID-19 death rate was 2.2 times that for U.K. patients. Between March 27, 2020, and April 24, 2020, the U.S. death rate for COVID-19 rose from 0.9/ 100,000 to 27.9 per 100,000, 31 times what the rate was a month earlier.

By May 27, 2020, the U.S. death rate was at 57.2 patients per 100,000 population. The death rate had more than doubled during the month of May. In the United States more than 100,000 people had already died from COVID-19 infections by May 31, 2020.

Secondary analysis: Case fatality rate = (# of deaths/ # confirmed cases) x 100.

World Health Organization (2020, August 4). Estimating mortality from COVID-19.

As figure 8 also shows, the death rate for the U.S. was 1.9 times that for the U.K. at the end of May of 2020.

Case fatality rates for the U.K. began to rise quickly, increasing from 0 to 5.0% at the end of March to 13.6% the next month in April, and then to 14.1% by May 27, 2020. In a similar manner, but showing a less pronounced curve, U.S. case fatality rates went from 0 in February to 1.5% in March to 5.1% in April, and then to 6.0% by the end of May 2020.

At best, the case fatality rate was an estimate early in this pandemic because testing was limited due to shortages of manufacturers and the supplies needed for the test kits. In addition, there was no way to accurately determine the number of people with asymptomatic infection. However, despite these serious limitations, this rate provides a picture of what nurses experienced in the field while a never-ending flow of very sick and dying patients required their care.

We have been unable to identify the reason for the jumps in case fatality rates during this time period. It is not clear if the ancestral SARS-CoV-2 was still the primary circulating variant or if these marked increases were due to an unrecognized, more virulent variant.

The healthcare systems in both the U.S. and the U.K. were strained beyond limits by the sheer volume of patients requiring care. Clinicians were also getting infected through healthcare acquired exposures. As shown in the chapter A Global Shortage of Personal Protective Equipment, and above, nurses were not adequately protected from exposure.

Given the steady flow of patients in desperate need of help, clinical staff would also have had to implement crisis standards of care without time to be oriented to the changes. In acute care hospitals, nurses were floated to emergency and critical care departments to assist with the demand, though they did not have critical care skills. How did health insurance status in the U.S. impact access to care and outcomes? We will likely never know the answers to these questions.

Political Divisions and an Inability to Fight Against a Common Enemy

Instead of uniting the country to address the threat posed by the SARS-CoV-2 virus during the crucial first months of the pandemic, there were a substantial number of politicians in the White House and both Houses of the U.S. Congress that prioritized their own political agendas. The disagreements that already existed in a deeply divided government were further exacerbated by conspiracy theorists.

If the deaths of more than 1.1 million Americans, and 7 million global citizens did not bring the U.S. Senators and Representatives together to fight this common enemy, then nothing ever will.

The U.S. Plan to Withdraw from the World Health Organization During the Pandemic in April of 2020

On April 16, 2020, the former President Trump announced that the United States would stop contributions to the United Nations World Health Organization and withdraw from membership (CDC, 2023, March 15).

Trump sent a letter to the Director General of the United Nations World Health Organization on May 18, 2020, stating that he was freezing funds to the World Health Organization. On May 30, 2020, in the middle of a global pandemic and without Congressional approval, he publicly announced that he was terminating the U.S. relationship and withdrawing.

The World Health Organization was at the center of the pandemic response, coordinating data collection, tracking outcomes, and communicating critical information worldwide. WHO was providing regular situation updates, operational updates, and epidemiological updates. The organization also provided information on variants and vaccinations. A tremendous amount of educational materials were produced.

A National Public Radio article provides insight into his reasons. Investigative reporting from other mainstream media provided similar reasons:

“To leave the organization, the U.S. is supposed to give a one-year notice and pay outstanding dues, according to language that the U.S. added to the WHO constitution when it joined the treaty in 1948. As of June 30, the U.S. owed $198 million in unpaid membership dues.

“Trump has repeatedly criticized WHO for being slow to respond to the pandemic and for being too ‘China-centric.’ On May 29, he announced his decision to leave the organization, claiming that it caved to pressure from China ‘to mislead the world when the virus was first discovered by Chinese authorities’ and that it’s under the ‘total control’ of China.” (Huang, 2020, July 7).

By July 2020, when the official statement of intent letter was sent to the World Health Organization, the U.S. had more than 2.4 million cumulative cases of COVID-19 and 132,000 Americans had died from this infection. Withdrawing from the organization that was coordinating the global response to SARS-CoV-2 did not make sense.

In this case, the system did work and withdrawal from the World Health Organization was delayed. As described below, the system of checks and balances stopped the planned withdrawal process.

The Congressional Research Service determined that the 1948 joint resolution adopted by Congress when the U.S. joined the World Health Organization stated that the U.S. could withdraw from the organization after one year notice and that financial obligations to the organization had to be met prior to withdrawing (Murrill & Hart, 2020 June 5). An official letter was sent by Trump’s Secretary of State on July 6, 2020, regarding the planned withdrawal in one year (Office of the Legal Adviser, U.S. Department of State, 2020).

A second Congressional Research Service report dated October 21, 2020, indicated that the U.S. could not legally withdraw from WHO until the one-year date on July 6, 2021, and that the U.S. was free to retract the notice of withdrawal any time prior to that date. The amount owed to WHO prior to withdrawal was not clarified (Salaam-Blyther, T., et al., 2020, October 21).

On his first day in office, President Biden sent a letter to his Excellency Antonio Gutteres, Secretary-General United Nations retracting the intended withdrawal, see figure 9.

Figure 9

Biden, J. R. (2021, January 20). Letter to his Excellency Antonio Gutteres, Secretary-General United Nations.

Superspreader Events Compound the Problem

In the US, politically motivated behaviors on the part of specific incumbent office holders and candidates running for a wide variety of national as well as local political positions impacted the rapid spread of COVID-19 through super-spreader rallies and other events. COVID-19 deniers frequently used “freedom of speech” as the conceptual basis for claiming that mask mandates, temporary shutdowns, vaccine mandates, and other public health measures introduced to reduce contagion were “un-Constitutional” (Mandavilli, & Tully, 2020).

Following the negative examples modelled by their leaders, a large proportion of the U.S. population refused to wear masks, to social distance, and to avoid crowds. This caused many superspreader events. Former president Trump continued to be one of the strongest voices against recommendations for social distancing and mask wearing. Even after he tested positive for COVID-19 and required hospitalization on October 2, 2020, he refused to wear a mask at press conferences and political rallies. It was not surprising that his followers also refused to wear masks and social distance (CDC, 2023, March 15).

Superspreader events are known to occur when one (or more) individual(s) at an event sheds more SARS-CoV-2 virus and transmits COVID-19 to a disproportionately large number of secondary people who then become ill or remain asymptomatic but pass the virus on. There are different types of scenarios that can impact the number of people at the event who become infected from contact with an individual superspreader, as well as the number of people who later become infected in the larger community as a result of superspreader event.

Environmental factors within the setting where the event occurs have a marked impact on the outcomes. Large, indoor gatherings, inadequate ventilation, without masks, and failure to stay more than six feet away from others, are known to create superspreader situations (Majra, et al, 2021).

“Worst case scenarios” for superspreader events exist when a lot of people are crammed in together, not wearing masks, with people from many other places, and with multiple days or activities within the event. Indoor with less ventilation is worse than outdoor (Dave, et al., 2021). In this kind of scenario there are numerous potential exposures for participants.

The term “superspreader” is used to describe a variety of different situations. Majra, et al. (2021) indicated that social superspreader events and isolated superspreader events are quite different.

Social superspreader events are those where people attend the event, sit near each other, eat or drink together, and mingle with others. Examples of social spreader events include religious services, work environments, schools, bars, shopping centers, conferences, sports events, and special occasions (Majra, et al., 2021), see figure 10.

When the event is over, people return to their families, workplaces, schools, attend religious services, use public transportation, etc., and it is difficult to determine the full effect of the secondary infections without thorough contact tracing.

With large social events such as concerts, sports events, big rallies, huge parties, etc., few participants know one another. In all likelihood, it would not be possible to identify participants should a superspreader event occur.

To some extent, individuals who have COVID-19 exposure apps turned on when their smartphones were present at the event may be able to receive an electronic notification from public health authorities in the event that a person who tests positive notifies the health department. However, with the degree of self-testing that is being done today, these features are likely not as helpful as was the case when positive results were reported to the local health department by the testing labs.

Isolated superspreader events occur when the group is separated from the larger community. Individuals are known. A few people from the isolated group may come in contact with the larger community but instituting a quarantine of those who were potentially exposed can limit the spread into the wider community. Examples of isolated superspreader events include exposures that occur in nursing homes, on ships, and prisons (Majra, et al., 2021).

An isolated superspreader event may involve a small number of people or a very large number of people who develop secondary infections. Retrospective analysis of large isolated superspreader events has provided a great deal of information about transmission characteristics, severity of infection and asymptomatic carriage as members of the group are followed during and often after quarantine, see figure 11.

The situation that occurred on the U.S.S. Theodore Roosevelt, a U.S. Navy aircraft carrier is an example of a large, isolated superspreader event. Of 4,779 personnel, 1,272 (26.6%) tested positive for COVID-19. Of those who tested positive, 76.9% (978) were asymptomatic when they tested positive and 55% of those crew members never did develop symptoms. This was a relatively young crew with a mean age of 27. Hospitalization and intensive care admissions were low and only one crew member died (Kasper, et al., 2020).

Another example of an isolated superspreader event occurred on the Diamond Princess cruise ship. The cruise departed from Japan on January 1, 2020, with 3,700 people on board (passengers and crew). Five days later, a man who was ill disembarked in Hong Kong and tested positive for COVID-19. Passengers had been in three countries during six stops before the ship returned to Japan, where Japanese authorities quarantined the ship on February 3, 2020.

Of the 3,711 passengers and crew, 712 (19.2%) tested positive for SARS-CoV-2 and of those 331 were asymptomatic at the time of testing, 46.5%. Of the 381 patients with symptoms, 9.7% (37) were sick enough to require critical care admission and 1.3% (9 patients) died. Passengers stayed in their cabins when quarantined, but crew members had to continue working. Three first responders in Japan were also infected, including one nurse. Of the 428 U.S. passengers and crew members who were followed through to March 13, 2020, 25.0% (107) tested positive for SARS-CoV-2, 11 were still in a hospital in Japan and 7 were seriously ill (Moriarty, et al., 2020).

One huge social superspreader event that has been studied was the Sturgis motorcycle rally held August 7 to 16, 2020 in Sturgis, South Dakota. Approximately 460,000 motorcyclists arrived in this small town (population 7,000) and county (population 26,000) for the 10-day event. There were no requirements for masks, social distancing, and there were numerous large events daily.

However, the city did offer masks to businesses, sanitized restroom stations, and provided dispensers of hand sanitizer in public locations. The city also tested first responders and rally workers, and provided daily health screenings (Dave, et al., 2021).

Dave et al. (2021) used anonymized cell phone data to evaluate the movement of people during this event. In addition to the influx of people into the area, the analysis of cell phone data showed that local people were also out and about more during this period of time.

South Dakota has a very low population density with only 900,000 people scattered over 77,000 square miles. COVID-19 cases in the state of South Dakota increased by 35% in the month following the rally and the South Dakota counties that had the most people attending the event experienced a 6.4 to 12.5% increase in COVID-19 cases.

The authors concluded that the Sturgis Motorcycle Rally generated public health costs of $3.8 to $8.7 billion dollars. (Dave, et al., 2021).

Bernheim, et al. (2020) analyzed the impact of 18 reelection campaign rallies where masks were not worn, and social distancing was nonexistent. Each was attended by the former president Trump where he was the primary speaker. He did not wear a mask and neither did most of his supporters. The researchers calculated that the 18 rallies resulted in over 30,000 new cases of COVID-19 infections and more than 700 deaths. Some of those who died had not attended the local rally. Rallies were held between June 20 and September 22, 2020 (Bernheim, et al, 2020).

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