Dr Krutika Kuppalli Assistant Professor of Medicine Division of Infectious Diseases Medical University of South Carolina Vice Chair Global Health Committee Infectious Diseases Society of America Testimony Submitted to United States House of Representatives Select Subcommittee on the Coronavirus Crisis Ensuring a Free Fair and Safe Election During the Coronavirus Pandemic September 9 2020 Thank you Chairman Clyburn Ranking Member Scalise and distinguished members of the Select Subcommittee for the opportunity to testify before you today I am extremely grateful for your interest and commitment towards helping support the novel Coronavirus Disease 2019 COVID-19 pandemic efforts in the United Sates as we attempt to contain this deadly disease and ensure we have a free fair and safe election for all citizens on November 3 2020 I am an Assistant Professor of Medicine in the Division of Infectious Diseases at the Medical University of South Carolina MUSC in Charleston South Carolina and the Vice Chair of the Global Health Committee for the Infectious Diseases Society of America IDSA a national professional organization that represents over 12 000 Infectious Diseases physicians researchers public health experts and other health professionals I am also an Emerging Leader in Biosecurity Fellow at the Johns Hopkins Center for Health Security During COVID-19 I have served as a subject matter expert for the San Francisco Department of Health as the city planned for a coronavirus surge and have provided expert scientific commentary to numerous organizations and media outlets since the beginning of the pandemic More recently I delivered expert testimony to the U S House of Representatives Financial Services Committee Task Force on Artificial Intelligence about “Exposure Notification and Contact Tracing How AI Helps Localities Reopen Safely and Researchers Find a Cure ”1 On behalf of IDSA I worked closely with the Brennan Center for Justice on joint guidelines we developed to inform “Healthy inperson Voting ”2 My expertise is based on my career as an infectious diseases physician that has focused on the clinical care of vulnerable patient populations global health research and clinical care of emerging infections outbreak preparedness and response and biosecurity I was on the frontlines of the 2014 West Africa Ebola outbreak in Sierra Leone where I was the medical director of a 70 bed Ebola Treatment Unit I subsequently helped lead the development and implementation of a United States government sponsored pandemic preparedness and response project in Africa and 1 have consulted on the development of therapeutics for emerging pathogens I have worked on the ground in Ethiopia India Sierra Leone Uganda and Haiti My background and experience makes me uniquely qualified to discuss policies to ensure a free fair and safe election during the coronavirus pandemic As the COVID-19 pandemic continues to spread across the United States and we prepare for the upcoming general election I hope to give you a greater understanding of this threat and actions we can take to maximize chances of a fair and safe election on November 3 2020 I will discuss measures necessary in the weeks leading up to the election to mitigate the risk of transmission outline important policies and procedures to be implemented by state and local elections officials public health leaders poll workers and voters to decrease risk of coronavirus transmission on Election Day and provide recommendations to leverage resources and collaborations to ensure appropriate monitoring testing and contact tracing related to potential exposures at polling sites Although November 3rd will look and feel different from every other election day in modern history it is critical that our principles of democracy not be undermined Election and public health officials must come together to ensure that every citizen who wants to vote in person can do so in a safe and healthy environment that minimizes their risk of contracting COVID-19 The Coronavirus Disease-2019 COVID-19 Pandemic On December 31 2019 cases of atypical pneumonia of unidentified etiology were reported in Wuhan China 3 Since then Severe Acute Respiratory Syndrome Coronavirus-2 SARS-CoV-2 the virus that causes COVID-19 has been declared a Public Health Emergency of International Concern PHEIC by the World Health Organization WHO It has infected more than 27 1 million individuals globally and caused over 889 000 reported fatalities 4 The first case of COVID-19 was detected in the United States in January and in the months since this occurred cases and fatalities in this country have risen disproportionately compared to the rest of the world 5 The United States comprises 4% of the global population but as of September 7 2020 accounts for 23 1% 6 28 million of COVID-19 cases and 21 2% 189 000 of fatalities worldwide 4 More concerning is the nationwide surge of over 40 000 cases daily that has occurred since lockdowns were lifted in the early summer months 6 U S Elections During Infectious Diseases Outbreaks Although the United States has dealt with multiple prior infectious diseases outbreaks we have never let one derail a midterm or presidential election 1918 Spanish Influenza Pandemic The 1918 influenza pandemic caused by H1N1 infected approximately 500 million people globally with at least 50 million fatalities 7 8 This pandemic occurred during a unique point in U S history as the country was actively involved in World War I WWI and was approaching midterm elections in November 1918 2 There were three waves of the influenza pandemic The first wave occurred after the infection was identified in military personnel during the spring of 1918 The second wave began in September 1918 near Boston and spread along the east coast leading to 195 000 deaths in October alone 9 As the pandemic rapidly propagated and midterm elections quickly approached public health officials implemented physical distancing and quarantine measures to help slow the spread of the infection Public gatherings were banned around the country and schools churches theaters bars and other gathering places were closed 8 Figure 1 Three waves of 1918 Spanish Flu Pandemic How Did the Spanish Influenza Pandemic Affect the 1918 Elections Due to public health measures implemented in advance of the 1918 election candidates were not able to campaign in their usual way They were prevented from having public rallies and unable to have direct lines of communication with the public They had to rely on newspaper advertisements and sending campaign materials through the mail to inform voters This led to controversy among candidates some of whom felt that public health officials were trying to influence the outcome of the election As the election approached the pandemic was improving on the east coast so officials lifted public health restrictions on schools and businesses before the election On the west coast things were worsening and in early October 1918 influenza quickly escalated from 169 to over 2 000 cases in one week This led San Francisco to issue a facemask ordinance for those in public as well as poll workers and voters at polling stations 9 The 1918 election presented numerous challenges including poll workers refusing to participate due to illness or fear of getting sick the need for inspectors to guard against overcrowding voting booths moved outside and the inability to open some polling locations on the west coast due to a lack of healthy citizens 8 10 Overall about 40% of eligible voters cast a ballot in the 1918 midterm elections which was a decrease of 10% 3 from the prior midterm election 8 The pandemic and WWI were the causative factors in the decline in voting The third wave of the pandemic occurred in the aftermath of the midterm elections This was related to lifting of public health measures before the election and the WWI armistice days after the election These two events prompted Americans to leave their houses for the first time in weeks Celebrating the end of WWI and the arrival home of soldiers while ignoring physical distancing and mask requirements resulted in a surge of influenza cases across the country and around the world 7 8 Global Elections During the COVID-19 Pandemic The COVID-19 pandemic has downstream impacts on elections globally as governments are forced to balance health and safety concerns of the public against the need for maintaining a democratic process Thus far more than 50 countries have proceeded with elections during the pandemic and though they are of varying scope the United States must learn from these experiences as we prepare for our own General Election on November 3 2020 11 South Korea On January 20 2020 South Korea identified its first case of COVID-19 and nearly three months later on April 15 2020 this country of 40 million people with nearly 10 600 confirmed cases and more than 220 deaths became the first country to hold a national election during the pandemic 11 Previous investment in outbreak preparedness and response allowed South Korea to respond expeditiously to develop innovative methods to ensure widespread testing and contact tracing and to institute policies to protect those at highest risk for infection elderly vulnerable populations and healthcare workers The South Korean government maintained clear communication and transparency throughout their response Amid debate about whether an election could be safely held during the pandemic President Moon Jae-in believed in South Korea’s sound public health capacity and pushed forward with the implementation of strong measures In the weeks leading up to the election cases of COVID-19 declined from a peak of 900 cases per day at the end of February to about 30 cases per day by the time the election occurred on schedule 11The election had record turn out with 66 2% of the population voting which was the highest in 20 years 12 This was in large part due to the government’s effectiveness at gaining public trust and providing a safe voting environment for its citizens during the pandemic The types of voting available for the election included resident voting overseas voting early voting and general voting 12 Before the elections the South Korean National Election Commission NEC produced a strong informational campaign to provide guidelines regarding the election 13 Additionally early advance voting was extended and used by 26 7% of voters 11 12 4 On Election Day polling stations were sanitized prior to initiation of voting with extra attention paid to high touch areas Stringent safety measures were implemented which included a Everyone wearing a mask - Only removed when a poll worker confirmed voter identification b Making voters maintain appropriate physical distance c Having voters undergo temperature checks - If 99 5 F they voted at a secluded polling location and were then tested for COVID-19 d Providing plastic gloves e Arranging pre-designated times for quarantined individuals to vote f Allowing vote by mail or at a early voting location Individuals with confirmed COVID-19 staying at hospitals or treatment centers and unable to visit polling stations were able to vote through residential voting These patients had to submit an application to receive a ballot by mail that was returned to the NEC The 13 642 people in quarantine who applied to vote were allowed to leave their houses at the end of the day after everyone else had voted 11 12 13 Overall the strict public health measures worked and South Korea had successful safe and healthy elections According to Director General for public health policy Yoon TaeHo “ Twenty-nine million voters participated in the April 15th parliamentary election…Not one case related to the election has been reported during the 14 days incubation period ”12 14 Elections in the United States during the COVID-19 Pandemic To optimize our chance of a safe election from a public health perspective all citizens must play a role in reducing community transmission A low community transmission rate on Election Day will minimize the chance of exposure and infection in voters poll workers and elections officials The scientific evidence demonstrates the following practices help to prevent the spread of COVID-19 15 a b c d Hand hygiene with soap and water or hand sanitizer with at least 60% alcohol Respiratory hygiene by sneezing or coughing into your arm Maintaining at least 6 feet of physical distance from others Wearing a mask that covers your nose and mouth and fits against the face What can we do prior to Election Day With coronavirus cases surging across the United States we must take bold steps to break chains of human-to-human transmission to improve both the short-term and longterm health of our populations and economic recovery of our country The federal government should strengthen our national response to COVID-19 with the following actions to significantly reduce community transmission in advance of Election Day 5 1 Issue a National Mandate Requiring the Use of Masks or Face Coverings Until we have a vaccine or a preventative therapeutic facemasks and physical distancing are the most effective public health measures we have to prevent COVID-19 The scientific evidence clearly demonstrates that viral load is highest in the 48-72 hours prior to developing symptoms of COVID-19 and a facemask helps to prevent the spread of infectious droplets when worn correctly A meta-analysis of 172 studies published in The Lancet showed that wearing facemask use could reduce the risk of infection by 85% 15 Most recent recommendations from the Centers for Disease Control and Prevention CDC states individuals over the age of 2 years old should wear facemasks in public that have the following components 16 a Two or more layers of washable breathable fabric b Covers the nose and mouth c Fits snugly against the side of the face 2 Expand Testing and Contact Tracing Capacity for COVID-19 It has been over seven months since the first case of COVID-19 was detected in the United States yet one of the greatest challenges remains the development and scale up of accurate and reliable testing The Kaiser Family Foundation compared models to calculate national-level testing capacity and determined that a robust strategy would require about 1 25 million tests day or 8 75 million per week which is about 2 7% of the U S population tested weekly 17 We continue to fall far below these targets due to lack of innovative testing swabs reagents and trained personnel Any new testing strategy must ensure equitable distribution throughout all communities with special emphasis on high-risk populations such as essential workers elderly racial ethnic minorities homeless and those with co-morbid medical conditions or living in congregate housing In addition outbreaks related to re-opening of colleges and universities places the institutions and surrounding communities at risk This is also a challenge that needs to be proactively addressed 18 Figure 2 COVID-19 cases by college counties vs other counties 6 In advance of the election we need to scale up testing to appropriately screen poll workers before and after the election In addition testing strategies and resources are imperative for in-person voters who become ill or come into contact with an ill individual Finally we need to focus on scaling up new modalities of testing that have recently been approved by the Food and Drug Administration FDA such as saliva and rapid tests Contact tracing often called the linchpin of an infectious diseases outbreak response needs to be expanded Identifying those who have been exposed and halting onward transmission is vital to contain the outbreak While many states have hired contact tracers additional federal resources infrastructure and training are required 19 Based on the current population and data experts estimate each case requires 10-25 contacts to be traced which requires at least 180 000-300 000 contact tracers 20 21 Recognizing the importance of contact tracing Johns Hopkins University has developed a free online course dedicated to training people in the principles of contact tracing https coronavirus jhu edu contact-tracing 3 Increase the Supply of Personal Protective Equipment PPE Due to inadequate supplies of PPE healthcare professionals remain at risk for COVID19 The CDC reports that over 143 000 health care personnel have become infected with COVID-19 with 1 077 deaths 22 The risk is exacerbated by a lack of a dependable PPE supply that forces healthcare workers to extend and reuse these resources even in areas where cases have declined Concerns regarding further strain on PPE supplies have arisen as polling locations around the country require them for Election Day Adequate PPE masks gloves gowns N95 respirators and face shields must be available in advance of the election so all poll workers can adequately protect themselves 4 Address Health Disparities The COVID-19 pandemic like many infectious diseases disproportionately affects vulnerable and disenfranchised populations Individuals at risk for COVID-19 are racial and ethnic minorities who tend to have jobs as essential workers It is difficult for them to access health care or take sick leave without worrying about losing wages or their job Non-Hispanic Black Non-Hispanic American Indian Alaska Natives and Hispanic Latinos have hospitalization rates of 4 6-5 3 times that of Non-Hispanic Whites The COVID-19 mortality rate in African Americans is 2 1 times higher than for Whites 20 Given these disparities resources must be allocated to address and respond to the disproportionate impact of COVID-19 on vulnerable populations 5 Provide Support for Individuals in Isolation and Quarantine Although isolation and quarantine are vital to break the chains of transmission on a societal level the process can result in significant emotional distress for the individual As a society we must identify and provide safe locations for isolation and quarantine ensure people have appropriate emotional support as well as paid sick leave food and access to medical care 7 Minimizing community transmission will maximize are ability for a free fair and safe Election Day What can we do on Election Day Fundamental to a democracy is the notion that all citizens have equal access to political participation In this era of COVID-19 personal health concerns have the potential to skew voter participation unless we provide viable nationwide alternatives to a single day of in-person voting Consideration must be given to options such as mail-in voting early longer voting more days and or longer hours more polling locations ballot drop boxes and or curbside voting For those individuals who will need to vote in-person it is important to have clear scientifically based guidance on how to safely conduct voting The following recommendations are based on evidence from science and public health to minimize risk to in-person voters to make the 2020 general election as safe as possible 2 23 This joint document published by the Brennan Center for Justice and the Infectious Diseases Society of America which I was proud to help author provides detailed guidelines for safe in-person voting 1 Government and Elections Officials A uniform evidence-based public health message about what voters should expect at polling sites is critical Messaging should emphasize that hand hygiene physical distancing of at least 6 feet and facemasks that cover the nose and mouth are imperative to prevent the transmission of COVID-19 Adopting and enforcing measures such as mask requirements now will decrease community transmission rates prior to the election and will increase compliance on Election Day 2 Polling Locations The following should be considered when establishing polling locations a Polling locations should provide masks and hand sanitizer for all voters as a courtesy b Increase the number of polling locations to avoid overcrowding c Relocate polling locations from nursing homes long term care facilities and senior living facilities to protect older adults at greater risk for COVID-19 d Relocate polling locations to large well-ventilated areas that can accommodate physical distancing measures between individuals voting booths and poll workers Some considerations are utilizing • College and professional sports arenas • Convention centers 8 e f g h i j k • Large music venues • School gymnasiums or cafeterias • Large warehouses • Parking lots weather permitting If polling locations are changed vulnerable communities may be disproportionately affected which requires clear advanced communication Conduct check-in activities outdoors if weather and space permits Use plexiglass barriers between poll workers and voters Minimize lines as much as possible Have unidirectional flow into and out of the polling location and minimize the number of ingress egress locations preferable only one of each Have spaces marked on the ground to delineate appropriate physical distancing Polling locations should provide appropriate personal protective equipment PPE and training for all poll workers 3 Infection Prevention and Control IPC The virus that causes COVID-19 is primarily spread through respiratory droplets and to a lesser extent via contaminated surfaces Close sustained contact to an infected individual increases the risk of transmission Routine hygienic procedures such as hand hygiene environmental surface cleaning and disinfection will lower COVID-19 spread at voting locations General Recommendations a All polling locations should have adequate supplies of • Soap • Hand sanitizer with at least 60% alcohol • Paper towels • Disinfectant Wipes • No touch trash cans • EPA approved disinfectants24 b All individuals at polling locations voters poll workers monitors should wear a mask practice hand hygiene and maintain physical distancing to prevent spread of COVID-19 Hand Hygiene a Hand sanitizer with at least 60% alcohol should be available at entrances exits and each step in the voting process Voters should sanitize their hands • Upon entering the polling location • Before removing and placing masks to confirm identity • Before and after voting b Having poll workers at key sites throughout the voting process to place hand sanitizer into the hands of voters may optimize compliance with hand hygiene 9 c Handwashing stations should be available with soap and water disposable paper towels and no touch trash cans Masks a Polling sites should offer facemasks to individuals without one b All voters elections officials and poll workers should wear facemasks at all times c A voter should only remove their mask when the poll worker is confirming their identity d Information should be provided on how to appropriately wear remove and keep masks clean Physical Distancing a Voters elections officials and poll workers should remain at least 6 feet apart at all times b Polling locations should provide signs or other reminders such as floor markings to remind voters to keep their distance c There should be plans for line management to ensure physical distancing is maintained d There should be unidirectional flow and points of entry exit clearly marked Polling Locations a Voting should occur in large well-ventilated spaces to accommodate physical distancing measures necessary between individuals voting booths and poll workers b Ventilation systems should operate correctly and use of recirculated air should be avoided c Prior to the polling site being opened for voting it should be thoroughly cleaned with an EPA approved disinfectant 24 • Special attention should be given to high touch surfaces such as voting booths door handles registration desks chairs etc d Once the polling site is open high touch areas and public restrooms should be cleaned at least every four hours e Plexiglass barriers should separate poll workers from voters f All reusable items should be routinely disinfected voting machines laptops tablets etc g Consider wipeable covers for electronics h Give people disinfectant wipes so they can sanitize the voting booth surface i Where possible voters should be provided with disposable pens pencils or other devices to mark their ballots j For voters with disabilities who use headphones they should be single use or disposable If reusable they should be cleaned between each use k For those with a disability or who are ill curbside voting should be available with poll workers wearing a higher level of personal protective equipment 10 l After the polling location closes the entire facility should be cleaned and disinfected 4 Voters a The safest way to prevent transmission of COVID-19 is to vote by mail b If a person is unable to vote by mail they should check with local elections officials for alternative voting options in their area c Verify your voter registration polling location and special requirements prior to presenting to the site d Fill out a sample ballot prior to Election Day to make in person voting timeefficient e Try to vote at an off-peak time such as in the mid-morning f Arrive to the polling location early and be prepared to wait g Come alone and do not bring non-voting family members friends children or extraneous items to the polling location 5 Voters who are Sick a Alternative voting options should be provided for voters with symptoms those who are sick or known to have COVID-19 to minimize exposure of voters and poll workers b This should be a designated polling site or curbside voting c Poll workers should be provided PPE and trained in proper donning doffing • Respiratory Protections N-95 masks • Face Shields • Gowns • Gloves d Consider having testing available for sick individuals 6 Poll Workers a Wide scale campaigns to recruit extra poll workers particularly those from lower risk populations b Poll workers at higher risk for severe disease from COVID-19 can be assigned tasks that limit direct interaction with voters and other poll workers c Should be provided and trained in how to appropriately don doff and use personal protective equipment d Should be offered free testing for COVID-19 before and after their shifts at the polling locations e Individuals concerned about their personal risk for COVID-19 as a poll worker should consult their healthcare provider 7 Mail in Ballots a Individuals handling mail in ballots should use appropriate physical distancing and frequent hand hygiene 11 b Machines used to process ballots should be cleaned and disinfected routinely per the manufacturer’s guidance and instructions What we can do after Election Day After the election continued vigilance for COVID-19 cases necessitates expanded testing for voters and poll workers Public health departments need to monitor for outbreaks associated with polling locations in order to assess patterns of transmission and to perform contact tracing and exposure notifications Summary of Key Recommendations The current pandemic is an unprecedented event of our lifetime A free fair and safe election can be achieved with bipartisan support of an evidence-based approach to the voting process We encourage local elections officials to work closely with public health and infectious diseases experts to proactively develop an election plan The following key recommendations should be considered 1 In advance of the November 3rd election communicate a uniform message encouraging all citizens to wear facemasks physically distance and use hand hygiene to decrease rates of community transmission 2 Make numerous methods of voting available to the public 3 Establish polling locations in large well-ventilated areas with adequate space for physical distancing between voters poll workers and voting booths 4 Provide adequate supplies to support healthy hygiene at all polling sites 5 Recruit poll workers of all ages and back-ups to assist at polling locations and have mechanisms in place to test them before and after Election Day Unifying as a country and working to decrease rates of COVID-19 in our communities will not only help us have a safe election but also allow our country to emerge from this pandemic Now is the time to emphasize action for the greater good rather than for the individual Looking Forward COVID-19 is the greatest social health and economic threat of our generation this election and how we manage it will be a critical turning point in our history No one should have to choose between the right to vote or to be healthy We have the evidence knowledge and science to keep our public safe and we must use it because one new infection is one too many Thank you again for the opportunity to testify before you and I look forward to answering your questions 12 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Kuppalli K Exposure Notification and Contact Tracing How AI Helps Localities Reopen Safely and Researchers Find a Cure https financialservices house gov uploadedfiles hhrg-116-ba00-wstate-kuppallik20200708 pdf America TBC for J and TIDS of Guidelines for Healthy In-Person Voting ProMED https isid org 2019-novel-coronavirus Accessed February 10 2020 COVID-19 Dashboard for Johns Hopkins University Holshue ML DeBolt C Lindquist S et al First case of 2019 novel coronavirus in the United States N Engl J Med 2020 doi 10 1056 NEJMoa2001191 The COVID Tracking Project History of 1918 Flu Pandemic Pruitt S How the US Pulled Off Midterm Elections Amid the 1918 Flu Pandemic Klein C Why October 1918 Was America’s Deadliest Month Ever The National Archives Searcey D The Lessons of the Elections of 1918 The New York Times Kim C I voted in South Korea’s elections This is what democracy can look like in a pandemic Kim EY Kim EK Lee M Park HK Osong Public Health and Research Perspectives COVID-19 Public Health Measures During National Assembly Elections of the Republic of Korea 2020 11 4 158-163 Election N Of C Republic THE Korea OF Election Management in Response to COVID-19 2020 Cha S South Korea No new domestic Coronavirus cases no transmission from election World Econ Forum Chu DK Akl EA Duda S et al Physical distancing face masks and eye protection to prevent person-to-person transmission of SARS-CoV-2 and COVID19 a systematic review and meta-analysis Lancet 2020 395 10242 1973-1987 doi 10 1016 S0140-6736 20 31142-9 Prevention C for DC and How to Select Wear and Clean Your Mask What Testing Capacity Do We Need Kaiser Family Foundation Tracking Coronavirus Cases at U S Colleges and Universities New York Times Sun K Viboud C Impact of contact tracing on SARS-CoV-2 transmission Lancet Infect Dis 2020 doi 10 1016 S1473-3099 20 30357-1 IDSA Recommendations for COVID-19 Fall Surge Preparations https www idsociety org globalassets idsa public-health covid-19 covidpreparedness-policy-recommendations pdf Accessed July 7 2020 MacIntyre CR Case isolation contact tracing and physical distancing are pillars of COVID-19 pandemic control not optional choices Lancet Infect Dis 2020 3099 20 2020 04 23 20077024 doi 10 1016 S1473-3099 20 30512-0 CDC Coronavirus Disease 2019 https www cdc gov coronavirus 2019ncov cases-updates cases-in-us html Accessed July 7 2020 Prevention TC for DC and Considerations for Election Polling Locations and Voters Disinfectants for Use Against SARS-CoV-2 COVID-19 U S Environmental Protection Agency 13