COVID-19 at a Rural Arkansas Church, March 2020: 35 Cases Among 92 Attendees

Large gatherings carry a risk of spreading SARS-CoV-2. This investigation shows how much.

Image from the Centers for Disease Control and Prevention

How it came to light

On March 16, 2020 — the day national social distancing guidelines were released — the Arkansas Department of Health (ADH) learned of the first two COVID-19 cases in a rural county of about 25,000 people: a pastor, 57, and his wife, 56, of a local church ("church A").

• They attended church events on March 6–8, and developed fever and cough on March 10 (wife) and March 11 (husband). Before his symptoms began, the pastor led a Bible study on March 11.
• On March 12, hearing that other members had similar symptoms, he closed the church indefinitely. The couple were tested on March 13 and learned on March 16 they were positive.

The events

• March 6–8: a three-day children's event — two 1.5-hour indoor sessions on March 6 and 7, and two 1-hour sessions during regular services on March 8 — led by two guests from another state. Children collected offerings by hand from adults, bringing nearly everyone into brief close contact. On March 7, church members served a buffet. Most children and some adults sang.
• March 11: the Bible study, where most attendees sat apart in a large room and no one sang.

Of 94 people who might have attended, 19 (20%) went to both.

What the investigation found

ADH entered every Arkansas SARS-CoV-2 test into a database, interviewed people who tested positive, and monitored their close contacts. 92 of the 94 attendees were reached.

• The source: two attendees of the children's event fell ill on March 6 and 7 — the primary cases. They lived locally, had not traveled and had no known contact with a traveler or a confirmed case, so the virus was likely already spreading locally before anyone detected it. The two out-of-state guests fell ill on March 9–10 and later tested positive.
• The toll among attendees: 35 confirmed cases out of 92 — an attack rate of 38%, or 78% counting only the 45 who were tested (testing then was limited to people with cough, fever or shortness of breath). Seven were hospitalized and three died.

• Children were 35% of attendees but only 18% of those tested and 6% of cases, with no severe illness — in line with other reports of milder or silent infections in children. Their role in spreading the virus was still unknown.
• Older adults were no more likely than younger adults to fall ill, but six of the seven hospitalizations and all three deaths were among people 65 and older.

Beyond the church: contact tracing found at least 26 more confirmed cases among community members exposed to infected attendees; one was hospitalized and died. By April 22, 61 cases — with eight hospitalizations and four deaths — were linked directly or indirectly to the church events.

Cases among church A attendees by date of symptom onset. Image from the Centers for Disease Control and Prevention

Limitations

1. Some infections were probably missed: people did not seek tests, did not qualify under the rules of the time, or could not get one.
2. Undetected community spread was likely, so some patients may have been infected elsewhere.
3. Individual behavior — handshakes, hugs — was not recorded, so exposure risk could not be measured.
4. Cases beyond the church were probably undercounted: out-of-state spread could not be tracked, and patients may not have named church members as their exposure.

What it means

Even though the church closed as soon as illness was noticed, the virus spread widely within the congregation and into the community. High transmission had also been reported from hospitals, long-term care facilities, family gatherings and a choir practice. Faith-based organizations holding or resuming in-person services, funerals or other events should know the risk, and work with local health officials on how to apply the U.S. Government's guidelines for modifying activities to protect their members and communities.

Sources

Based on "High COVID-19 Attack Rate Among Attendees at Events at a Church — Arkansas, March 2020," by Allison James, Lesli Eagle, Cassandra Phillips, D. Stephen Hedges, Cathie Bodenhamer, Robin Brown, J. Gary Wheeler and Hannah Kirking, Morbidity and Mortality Weekly Report 69(20), Centers for Disease Control and Prevention; a work of the United States government in the public domain.