Screening and Testing
While we move toward widespread vaccination, screening and testing (along with other risk-mitigation measures) will continue to play a critical role in a society-wide response to the COVID-19 crisis. The Edmond J. Safra Center for Ethics at Harvard University has published a policy roadmap that lays out a path to pandemic resilience through massive testing combined with contact tracing and social isolation with strong social supports.
Screening and testing before entering a workplace or event space are strategies to reduce the chance that infectious individuals will put others at risk. Screening can include daily symptom questionnaires (taken either at home or upon arrival), sometimes called “daily attestations.”
There are two types of testing: lab-based testing based on PCR technology, and self-administered “rapid tests” based on lateral flow technology. For more information on scientific developments to watch in areas including tests, vaccines, and therapeutics, see Developments to Watch.
The implementation of screening and testing protocols for theaters will be a necessary area of consideration. Theaters should be aware of the many current issues around accuracy, availability, and ethics that may be relevant to these strategies.
Physical Distancing and De-Densification
De‑densification of shared spaces refers to reducing the number of people present in a space at any one time, and is a strategy that protects against all three routes of transmission. De‑densification can be achieved in many ways, including having only portions of a workforce come in on different shifts. De‑densification provides several benefits. With fewer people in the space, it is more likely that the ventilation and filtration targets are sufficient on a per-person basis. It creates more space for physical distancing. Physical distancing is important because it reduces potential droplet exposure, since most large droplets expelled in a cough or breath tend not to travel long distances, and also helps to reduce exposure to smaller aerosols, which will be more concentrated closer to the infectious individual.
Chains of Contact
When possible, it is prudent to group individuals in all areas of the theater into small, non-overlapping teams, or “pods,” and to eliminate any in-person contact between the teams. The value of this arrangement is that if someone on one team becomes infected with COVID-19, the only individuals they would have had contact with during the pre-symptomatic period would be a limited number of people on their own team. Though the infectious person’s entire team would have to self-quarantine, the other teams would not have to self-quarantine because they would not have had direct contact with the infectious individual. This strategy could be used to help minimize disruptions to work in the event of illness—although it is clear that further thought will have to be devoted to the best methods of implementing these recommendations in the deeply collaborative, high-contact environment of theater.
Objects can become contaminated when an infectious person with virus on their skin (e.g. from covering a cough) touches an object, or when airborne virus (e.g. exhaled by an infectious person) lands on an object. One way to reduce the chances of these contaminated objects serving as sources of transmission to other people who come into contact with them is to isolate objects so they only are used by a single person. This could involve making very clear plans for who will handle tools and specific pieces under construction in various shops. In the context of work spaces that have traditionally not had assigned seats, this strategy could be implemented by assigning a seat to each worker so that the objects at each seat are only touched by the worker assigned to sit there. In addition to isolating objects as much as possible, the best control against fomite transmission in any context is frequent hand washing.
Frequent hand washing is an important strategy to reduce the risk of transmission of COVID-19. Hand washing with soap counteracts viral transmission by removing and destroying any virus on someone’s hands. If hand washing is performed after touching a contaminated object but before touching one’s eyes, nose, or mouth, the risk of infection is minimized. To employ this strategy, theaters could encourage frequent hand washing by patrons and performers, and could also provide hand sanitizer at building and theater entrances and in the backstage area so performers and audience members can supplement hand washing with disinfection when they aren’t near a sink.
PPE for Staff
Personal protective equipment (PPE), when used in combination with other strategies, is an important way to protect employees and staff required to work together in close contact. Requiring individuals working together in person to wear masks reduces the risk of unknowingly transmitting the virus to other people. Training staff in mask donning and doffing (more information below), as well as in mask care if non-disposable masks are used, is critical.
Masks are a critical control strategy that provide a dual benefit—they protect others from you, and they protect you from others. Because this virus can spread from people who are asymptomatic, one may not know if one is currently infectious. Therefore, to protect others, we all need to wear a mask. This can help reduce droplet and airborne viral transmission by reducing the amount of aerosols emitted when an infectious person coughs, sneezes, speaks, or exhales. In public health, this is called “source control” because interventions address potential viral transmission at its source (i.e. the infectious person). In addition, masks can help protect the wearer by acting as a filter as we breathe in.
The effectiveness of masks is based largely on the two F’s: filtration and fit. Filtration refers to how many airborne particles are captured by a mask. Some of the factors that impact the effectiveness of a mask are the types of materials used, the number of layers of material, and the shape of the mask. In general, the most effective materials remove a high percentage of particles and droplets (i.e. have a high filtration efficiency) but also are easy to breathe through (i.e. have high breathability). The design of the mask also impacts filtration efficiency; masks with more layers of material remove more particles and droplets (i.e. have higher filtration efficiencies) than masks with a single layer of material. For example, common cloth masks may remove 50% of airborne particles (this depends a lot on the materials chosen for the mask), whereas a three-layer mask (e.g., blue surgical mask) may remove 70% or more. Higher filtration masks, such as an N95 or KF94 capture 95% and 94%, respectively, as the names imply. (There are also KN95 masks on the market that can work well, but there have been reports of counterfeit KN95 masks from China that may provide as low as 25% filtration. Therefore, caution should be taken when selecting these types of masks. The FDA has
a list of KN95 masks that are approved.)
According to the World Health Organization, at least three layers of material are desirable in a mask and the ideal ordering of materials would include a layer of cotton or a similar material closest to the face, a middle layer of synthetic non-woven material, and an outer layer of polypropylene, polyester, or a similar material. Outer coatings of wax or similar materials should not be added as these coatings are likely to block airflow through the mask which reduces breathability and causes air to flow unfiltered around the edges of the mask.
Mask type can be selected based on the activity and level of risk associated with each activity. For low-risk activities, a three-layer mask is appropriate. For higher-risk activities, masks with a higher efficiency are appropriate. Fit is also critically important, and this refers to how well the mask conforms to a person’s face. The goal is to ensure that air passes through the filtering layer of the mask rather than escaping out the sides or top of the mask where there is not a good fit on the face. If the mask does not sit and stay close to the facial features as the wearer breathes or speaks, it is possible for the particles and droplets they expel to travel unfiltered around the edges of the mask, which can significantly reduce the overall effectiveness of the mask.
In addition, care and maintenance are important to maintain an effective mask. Masks should not be touched while they are being worn, should not be shared between people, and should be removed if they become wet or dirty. When removing a mask, care should be taken to avoid touching the fabric that sits in front of the mouth and nose, and the mask should be immediately disposed of or placed in a sealed container until it can be washed. Hand washing should be performed immediately after removing a mask. Reusable masks should be washed delicately in the highest temperature water the material can tolerate.
With England in lockdown 3, it’s time ministers got it right on face masks
Joe Allen stresses the importance of masks in mitigating the spread of COVID-19 in this January 2021 op-ed for The Guardian.
Joe Allen stresses the importance of masks in mitigating the spread of COVID-19 in this January 2021 op-ed for The Guardian.
Creating a Culture of Health
A.R.T. and the Healthy Buildings Program recognize that creating a culture of health, safety, and shared responsibility among theater staff, artists, and audiences can play an important role in the success of any risk reduction plan. This common understanding might be effectively established through a combination of information sharing, educational forums, regularly scheduled discussions of new concerns or policies, community agreements, independent assessments, and regular self-attestations of health and compliance.
As the A.R.T. has worked to update its facilities, practices, and policies to minimize risks associated with COVID-19, the A.R.T. and the Healthy Buildings Program developed a new educational program for the theater’s staff to establish a baseline understanding of public health and infectious disease transmission, to explain the strategies and rationale for changes to theater facilities and processes to reduce COVID-19 risks, to update staff regularly on the latest guidance and recommendations around disease transmission and risk-reduction, to address department-specific questions and concerns, and to create a forum for open dialogue.
This program, “Creating a Culture of Health, Safety, and Shared Responsibility,” has included the following components:
- Foundational Forums: The Healthy Buildings Program led three foundational forums in August 2020 for the entire A.R.T. staff. Each hour-long module included twenty-five minutes of expert presentations followed by thirty-five minutes of question-and-answer. The topics of these educational modules were: “Understanding COVID-19 and the Risk-Reduction Framework,” “Healthy Building Strategies for Theater,” and “Shared Responsibilities for Risk Reduction.” The modules fostered greater collective understanding of the potential SARS-CoV-2 exposures present in a theater setting and the steps that are being taken to minimize the risks presented by COVID-19, as well as the limitations of these interventions. A.R.T. and the Healthy Buildings Program designed the modules to promote a higher level of compliance with new procedures and policies among staff, a higher level of comfort with the steps the theater is taking as it moves forward, and a higher level of confidence in explaining new procedures and policies when interacting with artists and, eventually, the public.
- Updates: The Healthy Buildings program met with the entire A.R.T. staff in November 2020 to share updates about disease transmission and risk-reduction strategies and take questions from the staff. These all-staff updates will continue in 2021.
- Sessions for Individual Departments: As the A.R.T. staff prepared for and then undertook in-person activities, the Healthy Buildings program met with A.R.T. teams in smaller groups to discuss department-specific questions and concerns, to review protocols for work in the Loeb Drama Center and OBERON, and to make site visits to the A.R.T. Scene Shop, the Loeb Drama Center, and OBERON.
When in-person rehearsals and performances with audiences resume, the A.R.T. and Healthy Buildings Program will extend the “Creating a Culture of Health, Safety, and Shared Responsibility” program to include briefings and check-ins to help artists and staff feel safe and understand their responsibilities, and also to evaluate whether additional precautions or policy modifications are necessary.
As organizations, businesses, and educational institutions reopen their spaces, many are asking staff and customers to acknowledge a community agreement or community compact. Developed in close conversation with the specific values, spaces, routines, and requirements of each organization, these agreements ask staff, artists, and audiences to commit in advance to upholding the organization’s safety protocols. The A.R.T. will draft a community agreement, to be shared when the theater is able to reopen.
Self-Assessments and Attestations
In concert with other interventions, agreements, and screening strategies, theaters might consider asking staff, artists, and audiences to complete regular health self-assessments and/or attestations of compliance with organizational health strategies. Completed on an app or online platform prior to arrival for in-person work, these attestations might require staff to certify that they have acted in concert with a theater’s stipulated safety precautions and are not experiencing any symptoms associated with COVID-19.
As part of Harvard University, all A.R.T. staff approved for in-person presence at any A.R.T. facilities must attest daily to their wellness using Crimson Clear, a COVID-19 Screening Certification and Self-Assessment that determines eligibility to enter a Harvard facility. All staff must also complete Harvard’s COVID-19 Safety Awareness Training prior to entering any Harvard facility.