The decision taken by the National Coronavirus Command Council and announced by President Cyril Ramaphosa on 26 May and contained in the regulations published by the Minister of Cooperative Governance and Traditional Affairs, Dr Nkosazana Dlamini Zuma, on 28 May that places of worship will be allowed to resume religious services of up to 50 people when the country moves to Alert Level 3 on 1 June 2020 is a serious public health concern.

Religious worship is an important part of the spiritual and emotional well-being of millions of South Africans and the right to freedom of religion is contained in our Constitution. The decision, however, to allow religious gatherings of up to 50 individuals compromises one of the few effective public health tools currently at our disposal against Covid-19, namely physical (social) distancing and is a setback for the country’s Covid-19 public health response.

There is growing evidence globally of SARS-CoV-2 transmission during religious gatherings where a few infected individuals transmit the virus to large numbers of attendees, some of whom die. Six examples are listed below:

1. On 18 February 2020, a 61-year-old congregant of Shincheonji Church in Daegu, South Korea tested positive for Covid-19 (“Patient 31”). By 20 February 2020, 15 more individuals connected to this church were found to have Covid-19. By 25 March 2020, this particular church cluster made up 5,080 of South Korea’s 9,137 cases.
2. Two infected individuals attended church events in Arkansas, US, between 6 March and 8 March 2020. Ninety-four individuals attended the event and 92 were traced. Of these 92, 35 (38%) were confirmed to have Covid-19 and three died. From contact with these infected individuals, a further 26 Covid-19 cases (who did not attend church) were confirmed in the community, with one death.
3. On 10 March, a choir practice at a church in Washington State, US, resulted in at least 28 confirmed cases of Covid-19 among the approximately 60 who attended the practice, with at least two confirmed Covid-19 deaths.
4. At least 51 cases and seven deaths have been linked to a church gathering that took place between 16 and 22 March in Kansas, US. It is believed that this event was attended by 150 to 200 individuals.
5. Following the death of a priest at a church in Texas, US, on 13 May, five members of the religious order that he lived with tested positive for Covid-19. Two of these were priests who had been involved in public masses from 2 May 2020. It is not known how many members of the congregation may have been infected.
6. Five tourists who were later found to have Covid-19 attended a prayer meeting in Free State, South Africa, between 10 and 11 March. At least 67 of the approximately 895 attendees were subsequently confirmed Covid-19 positive. There have been at least three deaths linked to this cluster. This event seeded cases into other provinces.

It has been noted by Yong and his colleagues who investigated two church clusters in Singapore that there are certain characteristics of religious gatherings that lend themselves to transmission of SARS-CoV-2:

1. These gatherings consist of prolonged repeated activities with individuals in close proximity, enabling the virus to be transmitted through droplets or fomites.
2. Social interactions at religious gatherings facilitate transmission of SARS-CoV-2. These interactions differ from settings where people do not know each other.
3. Singing, which is a common characteristic of religious worship across religions and denominations, can generate droplets in quantities that are similar to coughing.
4. Data from Pew Research Center suggests that 55% of South African adults attend weekly religious services. This equates to more than 20 million people attending religious services for an hour or two every week. With tens of thousands of religious services taking place weekly, the potential for SARS-CoV-2 transmission is immense. The data indicates that 59% of adults aged 40 and above attend weekly religious services in SA. A large proportion of this group is likely to be over the age of 60 or to have underlying medical conditions which are risk factors for severe Covid-19 infection and death. SA’s daily Covid-19 case numbers are on the increase. Current models suggest the “peak” in SA could take place between July and September. In various parts of the country, SA is experiencing community transmission and/or cluster transmission. In this context, the decision to allow religious gatherings under Alert Level 3 appears to be premature.

Ramaphosa’s address and the regulations published on 28 May make reference to the reopening of places of worship being subject to restrictions. Concerns regarding the implementations of these measures include the following:

1. Social (physical) distancing: The regulations indicate that numbers will be limited based on the size of the space available. This will require thousands of places of worship to determine the size of the space they have available and the numbers they can accommodate to allow for adequate physical distancing, and then to turn people away once they reach their limit. This appears to be neither feasible nor practical. The government is unlikely to have the capacity to monitor and enforce such restrictions.
2. Use of face masks: The evidence for the effectiveness of cloth face masks in preventing Covid-19 transmission is currently very limited. If worn correctly, they may prevent an infected individual from transmitting the virus to others. We remain concerned that the majority of South Africans do not appear to be wearing face masks correctly. The possibility of infected individuals who are not wearing masks or wearing them incorrectly transmitting the infection is a serious concern.
3. Hygiene measures: Given the short time-frame between the announcement that places of worship will be allowed to reopen and the intended date of reopening, as well as the costs associated with these measures, it is likely that a large proportion of places of worship will not have these measures in place. The government is unlikely to have the capacity to monitor and enforce this.

The decision to allow religious gatherings of up to 50 people has several public health and health system implications with respect to the Covid-19 response:

1. Contact tracing capacity: One of the cornerstones of SA’s response to Covid-19 has been the tracing of contacts of Covid-19 cases. Given SA’s current case numbers, the capacity to continue to do this is limited. With the transmission of Covid-19 in gatherings of potentially up to 50 people, SA’s contact tracing capacity will rapidly be exhausted.
2. Contact tracing feasibility: Contact tracing at religious gatherings would necessitate the keeping of registers for this to be effective. Anecdotal evidence in public facilities currently open suggests these registers are not capable of supporting effective contact tracing. Completing a register before entry to a religious institution may itself be a focus for transmission if not done properly. Short of quarantining the entire congregation, there would be no way to identify close contacts.
3. Testing capacity: South Africa’s testing capacity is currently under strain. There is a global shortage of test kits. The decision puts SA at risk of having more people to test who cannot be tested.
4. Hospital capacity: The key goal of the lockdown as articulated by Health Minister Zweli Mkhize was to “flatten the curve” to build health system capacity. That capacity is already being tested in parts of the country with community transmission of Covid-19. A potential surge of cases through infections at religious gatherings could undo the work that has been done to build capacity. This, in turn, may lead to deaths that could have been avoided due to lack of ICU beds, for example.
5. Health workforce morale: South Africa’s public health workforce (community health workers, epidemiologists and public health medicine specialists) have worked tirelessly to “flatten the curve”. Frontline health workers continue on a daily basis to manage Covid-19 patients to the best of their ability despite personal risk. On face value, this decision appears to undermine that work and has the potential to have a negative impact on the morale of SA’s health workforce.

Based on the public health implications of this decision, it is not immediately clear why it was taken. The lockdown regulations under Level 5 and Level 4 have forced religious bodies to think of different ways to ensure worship can continue in safe ways. Television and radio have been used to reach people with religious programming for decades. Support from government and other stakeholders for such alternatives to continue should, therefore, be encouraged and forms of worship that rely on sharing common physical spaces avoided.

It is our view that Ramaphosa and the National Coronavirus Command Council should reconsider and reverse their decision to allow religious gatherings at Alert Level 3 and Dlamini Zuma should revoke the said regulation in the interest of the health of the South African population. DM/MC

The College of Public Health Medicine (CPHM) is one of the Constituent Colleges of the Colleges of Medicine of South Africa. It has over 160 fellows distributed across the country, actively involved in contributions to controlling the spread of Covid-19 in South Africa.