Depo Steve Stack Filed

Case: 3:20-cv-00036-GFVT Doc #: 43 Filed: 06/15/20 Page: 1 of 100 - Page ID#: 447
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UNITED STATES DISTRICT COURT
EASTERN DISTRICT OF KENTUCKY
FRANKFORT DIVISION
CASE NUMBER: 3:20-cv-00036
TONY RAMSEK, et al., PLAINTIFFS,
vs.
ANDREW BESHEAR, et al., DEFENDANTS.
* * * * * * * *
DEPONENT: STEVEN STACK, M.D.
DATE: June 10, 2020
* * * * * * * *
LEE ANN GOFF

COURT REPORTER
B a r l o w
Raising the Bar
Reporting & Video Services, LLC
620 Washington Street
Covington, Kentucky 41011
(859) 261-8440
Barlow Reporting & Video Services, LLC

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1 The videotaped deposition of STEVEN STACK, M.D.,
2 taken for the purpose of discovery and/or use as
3 evidence in the within action, pursuant to notice,
4 heretofore taken via Zoom, on June 10, 2020, at
5 2:31 p.m., upon oral examination, and to be used in
6 accordance with the Federal Rules of Civil Procedure.
7
8 * * * * * * * *
9 APPEARANCES
10 VIA ZOOM
11
12 REPRESENTING THE PLAINTIFFS:
13 Christopher Wiest, Esq.
Chris Wiest, Atty at Law, PLLC
14 25 Town Center Boulevard
Suite 104
15 Crestview Hills, Kentucky 41017
and
16 Thomas B. Bruns, Esq.
Bruns, Connell, Vollmar & Armstrong, LLC
17 4750 Ashwood Drive
Suite 200
18 Cincinnati, Ohio 45241
19 REPRESENTING THE DEFENDANTS:
20 Wesley Duke, Esq.
Taylor Payne, Esq.
21 Travis Mayo, Esq.
Laura Tipton, Esq.
22 La Tasha Buckner, Esq.
General Counsel, Commonwealth of Kentucky
23 700 Capital Avenue
Suite 118
24 Frankfort, Kentucky 40601
25 ALSO PRESENT: Tina Barlow, Videographer

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1 I N D E X
2
3 Examination of STEVEN STACK, MD Page
4 BY MR. WIEST: 4
5 BY MR. DUKE: 82
6 BY MR. WIEST: 87
7 BY MR. DUKE: 98
8 BY MR. WIEST: 98
9
10
11 E X H I B I T S
12
13 Exhibit Page
14 Plaintiff's Exhibit Number 1 5

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1 STEVEN STACK, M.D.
2 called on behalf of the Plaintiff, after having been
3 first duly sworn, was examined and testified as follows:
4 CROSS-EXAMINATION
5 BY MR. WIEST:
6 Q. Just real quick, a couple housekeeping
7 matters. We did enter some stipulations, the Judge
8 did sign off on those. I've asked the court reporter
9 just to attach those to the record so the record is
10 clean.
11 Good afternoon, Dr. Stack. My name is Chris
12 Wiest and, along with Tom Bruns, who is also on this
13 call, I represent the plaintiffs in the matter of
14 Ramsey vs. Beshear. Two quick ground rules, and I'll
15 have a third ground rule for you in a couple minutes,
16 but -- and then we'll begin.
17 If you don't understand a question that I'm
18 asking, just ask me and I'll repeat it or rephrase
19 it. But if you do answer it, we're going to
20 understand -- or presume that you understood it. And
21 if you could listen to the question that I've asked
22 and answer it, we will get through this in fairly
23 short order, probably well short of the time that's
24 been allotted. I do have another ground rule, but
25 I'm going to get into it in a couple minutes after we

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1 do some introductory matters.
2 Your name is Dr. Steven Stack; correct?
3 A. That's correct.
4 Q. And you are the current commissioner of
5 public health for the Commonwealth of Kentucky;
6 right?
7 A. I am.
8 Q. And your background, as I understand it, is
9 in emergency medicine; right?
10 A. Correct.
11 Q. Can the court reporter go ahead and pull up
12 Exhibit 1, please?
13 (Plaintiff's Exhibit Number 1
14 was marked for identification.)
15 MR. WIEST: All right. Tina, can you scroll
16 down a little bit or zoom out? That's blank. Is it
17 showing for you?
18 COURT REPORTER: No, it's blank here.
19 MS. BARLOW: Yeah.
20 MR. WIEST: This is a problem. Can you try
21 to pull it up again? Close it.
22 MS. BARLOW: I am.
23 MR. WIEST: Here's what I'm going to do: I
24 can -- I think I can share a screen on mine. Why
25 don't we try it that way?

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1 MS. BARLOW: Okay. Can you see this one?
2 MR. WIEST: Yeah. That I can see.
3 MS. BARLOW: Is this okay? Chris, are you
4 okay with this one?
5 MR. WIEST: I -- all I see is your list.
6 That's what I see. Let me try, Tina, and see if it
7 works from my end, if that's okay.
8 MS. BARLOW: Okay.
9 MR. WIEST: I'm going to share screen maybe.
10 All right. Dr. Stack, can you see -- is that
11 showing?
12 THE WITNESS: Yes.
13 MR. WIEST: Okay. That's how we'll do this
14 today then, that's fine.
15 BY MR. WIEST:
16 Q. This is Exhibit 1, I've premarked it. It's
17 an outline of the website from the Office of the
18 Commissioner. Sir, it's got your biography on it.
19 Would you -- you agree with me that that is a fairly
20 accurate summary of your biography?
21 A. To the extent that it -- for what it shows,
22 yes.
23 Q. Okay. And just to be clear, your background
24 is not related to epidemiology or, or virology;
25 right?

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1 A. I'm an emergency physician by background and
2 training who has extensive public policy experience
3 and other attributes that are described in that
4 biography and other places.
5 Q. And I take it that, as an emergency room
6 doctor with your background, emergency room doctors
7 tend to be generalists, they -- they tend to be able
8 to handle whatever presents in the ER; right?
9 A. Emergency physicians are acute care
10 specialists trained in the treatment of acute injury
11 and illness in an unplanned manner.
12 Q. Okay. Have you ever testified in a -- in a
13 deposition before?
14 A. Yes. But quite a long time ago and not
15 related to me personally.
16 Q. Okay. Were you an expert witness in that
17 deposition?
18 A. No, I was a fact witness.
19 Q. Okay. Doctor, typically when experts give
20 opinions, they do so to a reasonable degree, in this
21 case, of medical certainty. And I am going to be
22 asking you some -- this is the third ground rule that
23 we didn't get into before: When I -- I'm going to be
24 asking you some questions that call for an opinion
25 today. And when I'm doing so and when you answer, if

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1 you can, I'd like you to give me your opinions to a
2 reasonable degree of medical certainty. And if you
3 can't do that in response to any question, I'd ask
4 you to let me know that you're not able to do that.
5 Otherwise we're going to presume the default, as you
6 answer, is that you're, you're giving your answers to
7 a reasonable degree of medical certainty; is that
8 fair?
9 A. Yes.
10 Q. Okay. We're going to be speaking today
11 about coronavirus and some of your public health
12 orders. And I presume that you have not personally
13 conducted any studies in the laboratory or otherwise
14 on coronavirus; right?
15 A. Correct.
16 Q. In other words, as you've been formulating
17 recommendations and issuing orders related to the
18 coronavirus, you've been, I'm assuming, relying on
19 the input or studies that have been conducted by
20 others versus laboratory research that you personally
21 have conducted; right?
22 A. Yes.
23 Q. Okay. As you've issued public health orders
24 or you've recommended others to do so related to the
25 coronavirus, would it be fair to say that your

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1 primary objective is saving the lives of Kentuckians?
2 A. Yes.
3 Q. And as you've formulated public health
4 orders, you've issued them because the science and
5 medical studies support them; right?
6 A. To the extent the science is known and
7 certain at the time. The science and knowledge of
8 this disease is fast evolving, and so I have to make
9 decisions and recommendations upon my then-current
10 knowledge and understanding available to those who do
11 the job that I do.
12 Q. And I take it as you've issued orders
13 related to activities or businesses, those have been
14 generated based on your assessment of risks and your
15 assessment of how to best minimize those risks of
16 spreading the coronavirus in terms of a particular
17 activity or a particular business; right?
18 A. That's a fair statement.
19 Q. Okay. And would you agree that if people
20 violate your orders or those issued by the Governor
21 related to the coronavirus, it can lead to deaths?
22 A. I believe if people choose a path of action
23 other than the ones I've recommended, they may
24 experience elevated risk of, of a bad outcome with
25 respect to their health and well-being.

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1 Q. And a bad outcome could include death;
2 right?
3 A. That is one possibility.
4 Q. And I take it that other possibilities are
5 that they contract the coronavirus and they
6 experience symptoms which, you know, as we know,
7 there's a wide variation of symptoms depending on
8 individual patients; right?
9 A. It could result in hospitalization, critical
10 care intervention in an intensive care unit,
11 mechanical ventilation, collapse of the respiratory
12 and circulatory system, or a number of other possible
13 consequences.
14 Q. Would you agree with me that death rates are
15 higher in people with certain comorbidity require --
16 or comorbidity issues?
17 MR. DUKE: I'm going to object to that
18 question -- this is Wesley Duke by the way -- as, as
19 kind of being out -- well, not kind of, but being
20 outside the scope of the order the judge issued in
21 regard to this deposition. I don't know whether that
22 question has anything to do with the issue of the
23 difference between in-person protests and, and the
24 other activities under mass gatherings.
25 MR. WIEST: Yeah. And, and just for the

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1 record, I've got to get to the background before I
2 get to the orders. And all of this is going to lead
3 into questions about the orders, so I'm just laying
4 the groundwork, Counsel.
5 THE WITNESS: Mr. Wiest, could you repeat
6 the question for me?
7 BY MR. WIEST:
8 Q. Yeah. The -- you would agree that death
9 rates and, and negative outcomes are higher in people
10 or groups of people with certain comorbidity issues;
11 right?
12 A. Yes.
13 Q. And it's also been higher with certain
14 groups of people that have characteristics that are
15 known, kind of, risk factors for certain groups of
16 people; right?
17 A. There are both known and unknown risk
18 factors. To the extent that those are known, yes, we
19 have identified some that elevate your risk.
20 Q. For instance, economically disadvantaged
21 people have seen higher death rates from coronavirus;
22 right?
23 A. I wouldn't disagree with that, but I think
24 that the evidence is more clear for certain other
25 characteristics.

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1 Q. And one characteristic, for instance,
2 certain minority groups, including African Americans,
3 have experienced higher death rates related to the
4 coronavirus; right?
5 A. In Kentucky that is undeniably true.
6 Q. I think we just talked about this, but
7 there's a lot of emerging science and a number of
8 studies that are coming out almost every day related
9 to the coronavirus; right?
10 A. There's an enormous volume of research
11 coming available every day, yes.
12 Q. Would you agree with me, as we look at the
13 research related to the coronavirus, that a
14 meta-analysis is the gold standard in terms of
15 medical research?
16 A. I would not.
17 Q. Okay. Would you agree with me that a study
18 that is not peer reviewed would be the bottom rung of
19 kind of the research studies that are out there
20 related to the coronavirus?
21 A. I would not -- not offer you an opinion
22 specifically on the relative weighting of the, the
23 various types of research.
24 Q. Okay. From what we currently know,
25 COVID-19, the novel coronavirus, is primarily spread

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1 by droplets from someone coughing, sneezing,
2 speaking, or shouting; right?
3 A. Yes.
4 Q. And Doctor, part of that -- I think we
5 should talk about this, but part of that
6 transition -- or transmission is when someone coughs
7 or speaks or sneezes or yells or sings, it projects
8 tiny droplets; right?
9 A. Yes.
10 Q. And then someone else, in terms of
11 transmission, would -- would essentially breathe that
12 in; right?
13 A. It could come in contact with their eyes,
14 their nose, or their mouth, or it could be inhaled
15 into the respiratory tract. All of those avenues are
16 common ways to receive those respiratory droplets
17 from another person.
18 Q. And so being closer than six feet, for
19 instance, to someone else would make them more at
20 risk of receiving those droplets; right?
21 A. The evidence supports that, yes.
22 Q. And for instance, let me give you another
23 hypothetical. If I were in the grocery store line
24 and, and waiting to go check out and someone were
25 behind me closer than six feet, but they sneezed or

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1 coughed into my back or in the back of my head,
2 that's less risky than being, say, face-to-face;
3 right?
4 A. There's relative risk. It depends on the
5 nature of the person who is standing near you,
6 whether they have infection or not, whether they have
7 a high viral load or not. So there's a number of
8 different variables that, that determine the specific
9 risk in a moment of time. To, to answer the general
10 question, any time that you are within proximity of
11 someone whose respiratory droplets can reach your
12 eyes, your nose, your mouth, or you can inhale them,
13 your risk of containing -- or contracting an
14 infection is elevated.
15 Q. Is there more risk being face-to-face versus
16 my face to the back of someone's head?
17 A. Again, it depends. There -- whether you
18 are -- it depends on the environments and where you
19 are. If you are face-to-face and you cough directly
20 at someone, that is a particularly high-risk
21 exposure. If you are standing in front of someone
22 who has a high viral load and they cough, those
23 droplets can become aerosolized, suspended in the
24 air, and inhaled, and you can still have significant
25 risk.

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1 Q. Okay. Doctor, there are some studies -- I
2 think there's something that just came out this week.
3 Are you aware of any research that suggests that
4 asymptomatic people are far less risky to spread the
5 coronavirus?
6 A. No. The jury is still out on that one,
7 quite literally. There was some misunderstanding
8 from the World Health Organization earlier this week
9 that they have since stepped back from. A New
10 England Journal article as recently as last week
11 raised the concern about asymptomatic spread and
12 perhaps that they could be as high as 40 percent of
13 cases.
14 Q. Okay. There are some other studies that
15 suggest that asymptomatic people are not as risky to
16 spread the coronavirus. Are you aware of any of
17 those?
18 A. As you've stated before and we established,
19 there's an incredible volume of research being
20 published daily, not all of which agrees with each
21 other. And I am aware of various opinions related to
22 the likelihood, or lack thereof, of asymptomatic
23 transmission of this disease.

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1 Q. Okay. Have you -- and I've just marked and
2 I've just shown you the first page of an exhibit,
3 it's Exhibit 2, related to asymptomatic spread of
4 coronavirus. Have you seen this before?
5 MR. DUKE: Mr. Wiest, we can't see that.
6 MR. BRUNS: Chris, we still have --
7 MR. WIEST: Let me do this, I think I need
8 to do a new share. Maybe. Here it is.
9 MR. DUKE: Okay. We have it.
10 BY MR. WIEST:
11 Q. Have you seen and -- and again, this will be
12 in the record, but have you seen this study about
13 asymptomatic COVID, Doctor?
14 A. I have not personally reviewed that
15 particular study.
16 Q. Okay. Doctor, some of the research that's
17 out there -- and I just want to know whether or not
18 you agree with this: Is the highest risk for
19 coronavirus transmission through large groups of
20 people that congregate close together in indoor
21 settings?
22 A. You used superlatives and those are not
23 going to be correct in all settings. So there is
24 elevated risk for people to be in close proximity to
25 each other. And when they do so in confined spaces,

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1 because the air doesn't circulate usually as, as much
2 and there could be a higher concentration, there can
3 be elevated risk in an interior setting, so that
4 would be correct. It is not necessarily the highest
5 risk situation, however.
6 Q. Okay. And I know that we've been looking at
7 some statistics. For coronavirus deaths, as those
8 have been reported, what's being reported are people
9 who, who have passed away with a diagnosis of
10 coronavirus; right?
11 A. Correct. If you have a -- if you have a
12 diagnosis of COVID-19 at the time of death, it is
13 felt to be contributory to your cause of death.
14 Q. Okay. And unless we do an autopsy on
15 someone, we don't know whether or not coronavirus was
16 merely present or was an actual cause of death;
17 correct?
18 A. As is often the case, a precise cause of
19 death is a professional medical determination that
20 requires judgment.
21 Q. Okay. And unless we do an autopsy, we don't
22 know whether or not coronavirus is an actual cause of
23 death or someone merely passed away with the virus;
24 right?
25 A. No. I would say an autopsy is not the

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1 determining factor. It's possible with other
2 diagnostic studies such as CT scans, laboratory
3 studies, other radiographs. It's possible via other
4 diagnostic tools to reach very compelling and more
5 certain diagnoses that don't, therefore, require an
6 autopsy for confirmation.
7 Q. Okay. And as, as numbers of corona -- as
8 deaths have been reported related to the coronavirus,
9 would it fair to say that most of the time that level
10 of analysis is not being conducted?
11 A. It would be fair to say that autopsies are
12 not routinely being conducted, but it is quite common
13 that those other types of studies, CT scans,
14 laboratory studies, radiographs, physical
15 examinations, that those are being done with high
16 frequency related to people who expire from the
17 coronavirus.
18 Q. And again, what -- the only thing that's
19 being reported though is you have the coronavirus and
20 you passed away; right?
21 A. The -- in most states, or in all states as I
22 understand it, the cause of death is determined by
23 the treating physician on a death certificate. And
24 they make their determination at that time based on
25 their best informed judgment and professional

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1 experience, what the primary cause of death was and
2 what factors contributed to it. So each treating
3 physician who declares or states a person's death has
4 to determine the causality between those different
5 contributing factors on the death certificate.
6 Q. Doctor, would you agree with me that the
7 studies in terms of outdoor versus indoor suggest
8 that the risk of coronavirus spread is reduced in
9 outdoor settings?
10 A. Depending on the nature of the interaction,
11 there is evidence to suggest outdoor settings can be
12 lower risk, all other things being equal.
13 Q. Okay. I'm curious -- here's another study
14 that's been out for a little while about the indoor
15 transmission of COVID. And there are some
16 conclusions that they make that essentially and --
17 you know, I'm looking right here, I'm going to go
18 down to the punch line for you and for me, in which
19 they say that it does not rule out outdoor
20 transmission of the virus, but they suggest that in
21 terms of what they've studied, it is indoor
22 transmission primarily that they're seeing.
23 Have you seen this study before? And I can
24 go back to the heading if you want to see it.
25 A. I have not seen that particular study.

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1 Q. Are you aware of any studies like it that
2 have reached similar conclusions in terms of risk
3 from outdoor versus indoor?
4 A. Well, each study is unique. And the
5 hallmark taught in medical school is the need to read
6 the Materials and Methods section to understand the
7 nature of the design of the study, which I have not
8 had the opportunity to do in this case.
9 Additionally, as I mentioned before, you
10 have to control a number of other variables to make
11 sure they're consistent over time. So ten people
12 standing 20 feet apart indoors is safer than ten
13 people standing three feet apart outdoors. In that
14 case I changed the distance between the individuals.
15 Ten people standing in silence next to each
16 other is different than ten people shouting or
17 singing next to each other in the same physical
18 space. So there are many variables that have to be
19 accounted for, so without accurate time to review
20 this particular study, it would be difficult to
21 determine if I have an opinion on whether I can or
22 can't agree with their conclusions.
23 Q. There are some studies out there that talk
24 about the wind dispersing the droplets in such a way
25 as to reduce the viral load outdoors. Do you agree

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1 or disagree with that?
2 A. In environments where there is more air
3 circulation and it diffuses the concentration of
4 viral particles and respiratory droplets, that would
5 be helpful to further reduce the likelihood of
6 infection, all other things being held equal.
7 Q. Because the risk of infection does depend in
8 part upon the load, if you will, of the droplets that
9 someone is receiving; right?
10 A. That is an important contributor, yes.
11 COURT REPORTER: Hold on one second.
12 MS. BARLOW: We have a Ms. Buckner that's
13 entering. Is that okay?
14 MR. WIEST: Yeah, that's fine.
15 MR. DUKE: Yes.
16 (Ms. Buckner entered the deposition.)
17 BY MR. WIEST:
18 Q. And I think you -- you've just acknowledged
19 this, Doctor, but I want to be clear, Harvard Medical
20 put out some guidance that stated, and I'm going to
21 quote it: Outdoors, air currents are more likely to
22 scatter and dilute the virus, making transmission
23 less likely than in a home, office, or other confined
24 space with limited air circulation. Do you agree
25 with that?

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1 A. I think that's a fair statement, again all
2 the other variables being considered.
3 Q. I'm going to talk about -- we're going to --
4 we're going to talk about indoor and outdoor
5 gatherings in a minute, the -- but let's talk about
6 indoor first. The coronavirus doesn't care if the
7 group of people are sitting next to each other in an
8 office conference room or on a church pew if they're
9 engaged in the same activity; right?
10 A. Yes.
11 Q. Okay. And I suppose in some ways -- and I
12 think we've talked about this, but maybe the office
13 conference room could be a little more risky if
14 someone is facing someone else versus a church pew
15 where you're -- where you're facing the back of
16 someone. Would you agree with that?
17 A. Again you've given me a good opportunity to
18 explicate why those may or may not be similar risks.
19 Q. Right.
20 A. If someone is sitting in a, in a pew and
21 there's a concentration of people, if there's a more
22 dense concentration, the risk could be elevated even
23 if they're not face-to-face. If the individuals are
24 singing in church, whereas they are silent or just
25 speaking in the office complex, the nature of singing

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1 and projecting a greater volume over a greater
2 distance, the respiratory droplets could increase the
3 risk of spreading infection. So again, unfortunately
4 there are many variables. It depends whether or not
5 they are all similar across the different settings.
6 And, and each situation therefore would have to be
7 analyzed on its own merits.
8 Q. Okay. Doctor, the World Health Organization
9 has put out some guidance on social distancing. And
10 they are suggesting one meter, which is three feet
11 and some change, as appropriate. I know we've been
12 six feet in the United States and in Kentucky and
13 CDC. Do you have any opinions about the World Health
14 Organization guidance on the one meter distance?
15 A. I can offer you my understanding on this.
16 Typically it is felt, at least based on some research
17 done in the past, that in normal conversation
18 respiratory droplets may remain suspended in the air
19 for approximately three feet. I believe that the CDC
20 added a margin of error to that, so they doubled the
21 distance to increase the likelihood there was a safe
22 distance and lower the risk of disease transmission.
23 In some situations the respiratory droplets
24 can go substantially farther than six feet if you are
25 shouting or screaming or singing loud or any of those

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1 sorts of -- sneezing or coughing where you have
2 forceful expulsion of air. So in this case it could
3 well be that the World Health Organization referenced
4 this specific research and that they said that three
5 feet is the distance beyond which it is less likely
6 you get exposed, and that a different public health
7 expert body has determined that adding a margin of
8 safety is in the best interest of public health;
9 hence we arrive at this CDC guidance of six feet,
10 which Kentucky has generally followed.
11 Q. Doctor, I'm going to take about -- I want to
12 talk about face masks very quickly and then we're
13 going to get into -- because that's in some of these
14 orders and I want to talk about it. And then we're
15 going to get into some other items and specifics of
16 the orders. Are you aware of any research that
17 suggests that face masks can actually do more harm
18 than good?
19 A. Well, the proper use of the face mask is
20 very important. And the thinking on the face mask
21 has evolved over time. The current thinking most
22 widely expounded upon for why we advise the use of
23 face masks, it's so that in the event someone has the
24 coronavirus infection and they are coughing or
25 talking or sneezing or laughing, that they don't

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1 spread it to other people.
2 So it is believed and it is felt that the
3 evidence -- the preponderance of evidence supports
4 that it reduces the transmission of the illness from
5 an infected person to someone else who may not be
6 infected. As to whether it protects the wearer of
7 the mask themself from receiving infection from
8 others, the evidence is conflicting on how great the
9 value is to the person wearing the mask in protecting
10 them from receiving infection from others.
11 Q. So said another way, the mask wearing is
12 about protecting the public and not the wearer;
13 right?
14 A. Predominantly. There is some -- there's
15 thought to be some benefit. Obviously in the example
16 you've used multiple times, if you and I are sitting
17 across from each other in close proximity and talking
18 or, or shouting or singing at each other, or one of
19 us sneezes, if I'm wearing a mask, the -- the air and
20 the virus particles could theoretically get around
21 that mask, but it likely is going to catch on the
22 front of the mask the brunt of the respiratory
23 secretions you send my direction. So it's felt there
24 is some protective value, but it is not the same as
25 the medical grade mask properly worn in a healthcare

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1 setting.
4 Q. Okay. Let's go -- we're going to look at
5 one quick study. This is Exhibit 6 maybe.
6 Doctor, have you seen this study? This is a
7 study on a cluster randomized trial of cloth masks
8 compared with medical masks in healthcare workers.
9 Have you -- have you seen or had the opportunity to
10 see this study before?
11 A. Not this particular study, sir, no.
12 Q. Okay. And if this study were to conclude
13 that the use of cloth masks can actually increase the
14 risk of infection because people don't wash them --
15 they reuse them from day to day without washing them,
16 and people are not disciplined in their use, would
17 you have any reason to disagree with that?
18 A. Well, I would but, but perhaps not for the
19 reason that you anticipate. There is certainly a
20 risk that a mask not properly cared for or properly
21 used could expose the user of it or the wearer of it
22 to infection, but it would still have value in
23 keeping a person's contamination to themselves and
24 away from others.
25 And so determining whether the preponderance

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1 of good or bad, you know, which of the two was more
2 dominant would really depend on the circumstances.
3 So your mask may be very dirty if you wear it, but as
4 long as I stay six feet away from you, and if you
5 cough it is still likely to keep me protected more
6 than if you are not wearing it. It may not protect
7 you very well though if you don't care for it
8 properly and it picks up debris from other people.
9 Q. Doctor, I'm going to turn to the context of
10 this case and some of the gatherings, and I want to
11 talk in the context of protests. In a protest or, or
12 a gathering to protest, there's typically someone
13 talking to the group that's been gathered; right?
14 Someone's using a microphone; right?
15 A. That's one form of protest, yes.
16 Q. And then there's people that are gathered
17 around to hear them and possibly to speak or shout
18 back at them; right?
19 A. Again, that is a common form of protest or
20 gathering.
21 Q. And just to be clear, the coronavirus does
22 not differentiate based on the content of what is
23 being protested; right?
24 A. The meaning conveyed by the verbal
25 utterances does not affect the transmission of the

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1 viral particles.
2 Q. Okay. And so if -- whether I'm protesting
3 lockdown orders or I'm marching for Black Lives
4 Matter, the virus makes no distinction in terms of
5 the content of the protests; right?
6 MR. DUKE: I'm going to object to that.
7 Again, this is Wesley Duke. And I know we had to lay
8 the background to this, but I think this -- that
9 question and this line of questioning is outside of
10 the scope of the judge's order in regard to the --
11 his direction on why we're here today.
12 THE WITNESS: Should I proceed on that?
13 MR. DUKE: Yes, sir.
14 THE WITNESS: Okay. So, Mr. Wiest, to your
15 question -- would you repeat that one more time?
16 BY MR. WIEST:
17 Q. Right. Whether you're protesting lockdown
18 orders or you're marching for Black Lives Matter, the
19 virus makes no distinction on the purpose of the
20 protest; right?
21 A. The purpose of the communication or, or the
22 verbal utterances does not have bearing on the risk
23 of transmission of the disease.
24 Q. If, if people are protesting and they stand
25 about six feet apart and they wear masks and the

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1 protest is outdoors, is that more or less risky than
2 sitting in a church pew six feet -- six feet apart
3 from the next family singing?
4 A. Well, you've -- you've controlled the
5 variables. So if people adhere to those variables,
6 meaning that they all stay six feet apart, that they
7 all keep their masks on at all times, if they engage
8 in similar behavior, the activities could in many
9 ways be similar. Where they are not similar
10 necessarily is most churches don't have the capacity
11 to hold the number of people that could gather in an
12 outside space. And any time you increase the number
13 of people who come together, you increase the
14 probability that infected people come in close
15 proximity with uninfected people, spread the disease,
16 and that they subsequently take that back to, to
17 their homes or to their other communities which may
18 be, you know, disparate.
19 Q. Does it matter -- is the risk the same if
20 those people that have gathered for the protest stand
21 six feet apart, assuming that they do?
22 A. Please clarify that. When you say is it
23 similar, is it similar to what?
24 Q. Well, I mean -- my, my question is: If the
25 people at the protest are standing six feet apart

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1 from each other, if they're wearing masks, does it
2 really matter how many of them gather as long as
3 they're adhering to those protocols?
4 A. Well, it does because all of these things
5 are risk-reduction strategies, none of them are
6 risk-elimination strategies. There is no strategy
7 available, other than remaining in complete isolation
8 from each other until we find a prevention,
9 treatment, or cure for this disease, to effectively
10 keep everyone from becoming infected. So any time
11 people come within proximity to each other, is a risk
12 of transmission of the disease.
13 And the recommendations that I have offered
14 have been ones that are risk-reduction strategies
15 that can lower the likelihood of disease
16 transmission. And I think in follow-up or conclusion
17 to that, Mr. Wiest, if you bring together 5,000
18 people versus 50 people, the risk of infection
19 increases substantially simply because you have many
20 more people interacting with each other, where the
21 risk and the likelihood of transmitting disease
22 increases as a direct result.
25 Q. Doctor, I'm going to look at -- I'm going to

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1 look at Exhibit 7. It's the May -- oh, I'm sorry,
2 March 19th, and it was amended on May 9th, gathering
3 ban. All right. And I'm sure -- I'm going to just
4 scroll down real quick. You are familiar with this
5 order because you signed it; right?
6 A. I am familiar with this order.
7 Q. And this order says all mass gatherings are
8 banned; right?
9 A. Yes.
10 Q. And it goes on to say, "Mass gatherings
11 include any event or convening that brings together
12 groups of individuals, including, but not limited to,
13 community, civic, public, leisure, faith-based, or
14 sporting events; parades; concerts; festivals;
15 conventions; fundraisers; and similar activities";
16 right?
17 A. You appear to have read that correctly.
18 Q. And then it goes on to say, "For the
19 avoidance of doubt, a mass gathering does not include
20 normal operations at airports, bus and train
21 stations, medical facilities, libraries, shopping
22 malls and centers, or other spaces where persons may
23 be in transit. It also does not include typical
24 office environments, factories, or retail or grocery
25 stores where large numbers of people are present, but

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1 maintain appropriate social distancing"; right?
2 A. You have reasonably read the next phrase,
3 yes -- its next line, yes.
4 Q. Let me ask, first of all, what peer-reviewed
5 studies are you aware of that quantify the risk of
6 outdoor transmission versus indoor transmission, all
7 other variables being equal? Sorry to back up on
8 you, but I needed to pin that down.
9 A. Repeat that one more time for me, it was --
10 Q. Yeah. Are you aware of any peer-reviewed
11 studies that you're relying on that would quantify
12 the risk of outdoor transmission versus indoor
13 transmission, all other variables being equal?
14 A. Well, I have read studies I don't have in
15 front of me here, but I have read, you know, academic
16 materials that have talked about the differential
17 likelihood of transmission inside, outside and, and
18 across many other factors that could contribute to
19 the spread of infection. I, I don't have a specific
20 reference to offer you at this time though.
21 Q. Okay. Are you aware as you sit here today
22 of any research that exists showing outbreaks related
23 to outdoor activities?
24 A. The answer is -- the answer is yes. There
25 have been outbreaks that were related to outdoor

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1 gatherings and outdoor events that have resulted in
2 the transmission. And I would have no difficulty
3 finding those, though I don't have them in front of
4 me at the moment.
5 Q. Okay. I'm going to look -- and Doctor, I am
6 aware that there was an amendment to this order,
7 we're going to scroll down and look at it, this was
8 May 9th, that allowed for -- oh, let me back up.
9 What is the difference in outdoor
10 transmission rates versus indoor?
11 A. Again, all -- all variables being held
12 equally, the outdoor transmission rate is probably,
13 you know, to some degree lower than the indoor
14 transmission rate because there's more air
15 circulation and other variables such as the sunlight
16 help to lower the risk. But it does not eliminate
17 the risk. And again, the nature of the interaction
18 between the people participating in the gathering,
19 whatever the nature of the gathering, also has direct
20 impact on the risk of infection and the spread.
21 Q. Can -- can you quantify how much lower that
22 risk is outdoors versus indoors?
23 A. I'm not aware of any, any accurate study
24 that can reasonably quantify that precisely. But
25 directionally, and in a general sense, you know,

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1 publications and my understanding of those
2 publications has been that places where there is
3 greater air circulation such as an outdoor
4 environment can be lower risk.
5 Q. Okay. I want to -- this May 9th order that
6 allowed for the in-person worship, it did exempt
7 faith-based gatherings from the order, right, and it
8 put some conditions on those; correct?
9 A. Yes.
10 Q. And it explicitly carved out drive-in
11 services, right, from the -- from the order?
12 A. Yes.
13 Q. And one of the conditions -- and we're going
14 to look at it here in a second -- one of the
15 conditions that was put on worship was -- and by the
16 way, Doctor, we're going to look at some other orders
17 today and I see this a lot in the orders, 33 percent
18 of building occupancy capacity; right?
19 A. Yes, I see that. You have highlighted that
20 with the cursor.
21 Q. Right. And that is -- and that's for indoor
22 services; right?
23 A. In this document, yes.
24 Q. Okay. Is there any limit on outdoor
25 services in terms of the number of people that can

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1 attend?
2 A. Well, at the time that this document was
3 published, any mass gatherings were prohibited. We
4 had not even excepted gatherings up to ten people at
5 that point. So the only exceptions were very
6 specific situations and there were specific orders or
7 guidance documents written for those specific
8 situations.
9 Q. Okay. But just to be clear, this order on
10 churches does not have any size in the number of
11 people that can attend an outdoor worship service;
12 right?
13 A. Well, but different criterion apply to the
14 outdoor service. The outdoor service was a drive-in
15 service where people were in their own vehicles,
16 where they did not exchange items between
17 participants in other vehicles. So the description
18 of the permissible activity was different in the
19 outdoor environment than it was in the indoor
20 environment.
21 Q. Right. Well, we look at -- there's a 33
22 percent of building occupancy capacity. Do you see
23 that?
24 A. I do.
25 Q. There's no similar limit in terms of if

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1 you're going to hold it in-person,
2 out-of-your-vehicle outdoors, there's no limit on the
3 number of people; right?
4 A. Because each vehicle contains people from
5 only their household and there was no interaction
6 between the people in the different vehicles, and
7 therefore there was not the same requirement to, to
8 put the same type of physical distancing between the
9 vehicles because the vehicle itself served as the
10 barrier between other households.
11 Q. No, I understand the vehicle and I want
12 to -- I want to step away from the vehicles and I
13 want to talk -- and I want to step away from the
14 drive-ins. And I just want to look at, I'm going to
15 hold my church service in an outdoor environment, you
16 know, outdoor benches, amphitheater kind of
17 environment. There's no limit that this order puts
18 on the number of people that can attend; right?
19 A. Theoretically, if you have enough outdoor
20 space to contain vehicles that comply with the
21 requirements of an outdoor gathering, then you could
22 have a larger number of people, if that's what you're
23 asking.
24 Q. Well, Doctor, there's nothing in this order
25 that prohibits or, or restricts people that are

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1 outdoors from, from only doing it in their vehicles;
2 right?
3 A. Was this the order that happened -- this was
4 the -- can you scroll up to the date on this for me,
5 sir?
6 Q. Yeah, it was -- well, May 9th, and you can
7 also see the May 9th --
8 A. Okay.
9 Q. Yeah.
10 A. Correct, so yes. So this order was in
11 response to another court order where we amended the
12 previous guidance.
13 Q. Right.
14 A. We -- my advice, my preference would have
15 been at that point where we were still in phase one
16 of our reopening within the Commonwealth of Kentucky,
17 to have gatherings that did not have in-person, in
18 this particular route. The courts determined that
19 this was to be permitted, and so then we had to
20 adjust our risk reduction guidance in an attempt to
21 reduce the risk as much as we could, permissible with
22 what the courts would allow. So in this case, that
23 33 percent is an attempt to reduce the density of the
24 people within a confined space in order to further
25 reduce the risk of infection within what the Court

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1 would permit.
2 Q. No, and, and Doctor, I'm not quibbling with
3 the 33 percent indoor. My, my question is actually
4 related to people that are outdoors, that are out of
5 their cars in an outdoor -- what's called an outdoor
6 sanctuary setting. There is no limit to the number
7 of people under this order that can attend an outdoor
8 worship service out of their cars, the 33 percent is
9 for indoor services only; right?
10 A. This, this was -- yes. I mean, this
11 document does not specify interior or exterior
12 gatherings. This document was written with the
13 understanding that it was addressing people convening
14 within the confines of the church building itself.
15 Q. Well, Doctor, there's no building occupancy
16 in an outdoor setting. Building occupancy is for
17 indoor settings; right?
18 A. I -- I'd accept that. Yes. Yes.
19 Q. Okay. Let's look at another order. This
20 was another question that I had. There is a lot of
21 shoulds; should limit, should ensure. And in some of
22 your orders there are -- there are musts. Are
23 shoulds recommendations and musts things that people
24 have to do, or can, can you -- can you elaborate or
25 explain that for me?

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1 A. I would say the use of the word must and the
2 use of the word should are -- were used in their
3 commonly understood interpretation, meaning that must
4 is something that we have a high expectation that you
5 comply with, and should is a strong encouragement
6 that this is a behavior that we strongly urge you to
7 take.
8 Q. Okay. And if we were going to enforce this
9 against someone, the musts would be the ones that if
10 you did it, you could have your business shut down or
11 -- and, and the shoulds are things you're just really
12 asking people to do because it's the right thing to
13 do and it's the safe thing to do; is that fair?
14 A. I think in a general sense that that -- that
15 would be correct, that yes, that the musts are the
16 ones that a transgression of are the, are the ones
17 that are more likely to be enforced than the shoulds.
18 And that the shoulds, we would probably use education
19 as a tool to encourage people to follow those
20 behaviors.
23 Q. Okay. I'll put up another one. This is
24 Exhibit 8. This is an order that came out May 22nd,
25 2020. This is another order that I believe you

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1 signed and Secretary Friedlander signed; right?
2 A. Yes, sir.
3 Q. And I want to go down and, and look at
4 restaurants. And if we look at restaurants, we see
5 again, and this is a theme, the 33 percent of
6 building --
7 MR. DUKE: I want to go -- I'd like to make
8 an objection here. This is Wesley Duke again. This
9 order does not involve mass gatherings, and that's
10 what, once again, the scope of the deposition today
11 is about in-person protests and other mass gatherings
12 currently allowed. This is a separate order that,
13 that -- that does not involve mass gatherings.
14 MR. WIEST: Well, if you recall, Counsel,
15 the 6th Circuit directed us to compare and contrast
16 all of these orders in all of these contexts, which,
17 I mean, this is -- this is right on scope. I
18 understand your objection; we're going to continue.
19 BY MR. WIEST:
20 Q. Dr. Stack, this is another one, 33 percent
21 of building capacity. Do you see that?
22 A. I do.
23 Q. I take it when we look at building capacity,
24 we know that if we're at capacity it's a very crowded
25 building; right? If it's filled with people to

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1 capacity; is that fair?
2 A. I would -- in general terms, yes, I would
3 agree. It depends how you define to capacity, but
4 yes, in common understanding, I would accept that.
5 Q. Well, capacity is actually a legally
6 permitted building occupancy; correct?
7 A. Right. Now that you've defined that, if
8 you're following the legally defined building
9 capacity, then yes, if it is reaching that capacity
10 it is relatively full, yes.
11 Q. Right. And when you're using the term
12 maximum permitted occupancy, you're using the
13 building code understanding of that, or how many
14 people the fire marshal will allow in the building;
15 right?
16 A. Yes.
17 Q. And the -- you and Secretary Friedlander and
18 others have made the determination -- by the way, I'm
19 not questioning it at all -- that right now what is
20 okay is a third of that; 33 percent of that capacity
21 is okay in terms of how many people can be there,
22 subject to the requirement that whoever is there, if
23 you're not of the same household, you need to keep
24 six feet apart from, from other households; right?
25 A. The only -- the only clarification I'd give

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1 is, I wouldn't say I'm okay with it; I'd say that we
2 permit it because it is necessary as part of a phase
3 one reopening. Ideally from a public health
4 standpoint, we would like to keep people away from
5 each other so that they don't spread infection, but
6 there are counterbalancing considerations in society.
7 And, and so in this case, attempting to comply with
8 the general nature of guidance that the federal
9 government has afforded us and other states are
10 trying to do, we have allowed 33 percent of the
11 maximum capacity of a building in this case.
12 Q. Okay. You would agree that if people are in
13 different vehicles, automobiles, at the drive-in
14 service from different households, there's no risk to
15 a drive-in service, is there?
16 A. There's very low risk. I can never say
17 there's no risk, but I'd say it's very low risk.
18 Q. Okay. And that's why, for instance, out on
19 the highways if cars are, you know, bumper to bumper
20 in morning traffic going into or out of a city, I
21 mean, there's not really high risk for that activity
22 if people are in separate cars; right?
23 A. I'd even agree with you that that is low
24 risk.
25 Q. Okay. When we look at the dining, and

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1 that's what we're looking at here, there is some risk
2 to food being prepared; right?
3 A. Yes.
4 Q. And there's some risk to serving drinks;
5 right?
6 A. Yes.
7 Q. And let me ask, in terms of, you know, food
8 being prepared or serving drinks, is that -- is that
9 more risky or less risky than talking to someone
10 face-to-face?
11 A. I would say again, my inclination is to be
12 helpful here, but it's also not to have you
13 misunderstand what I intend. So when someone is
14 talking face-to-face, that is -- particularly when
15 they're not wearing a mask, that is a high-risk event
16 of transmitting COVID-19 if one of the two
17 individuals is infected.
18 It is lower risk, in my assessment, if
19 someone shares an object or -- between each other,
20 because transmission by contact surfaces is a lower
21 risk overall. But it is not a risk-free exposure,
22 particularly when an infected person touches an
23 object and hands it immediately to another.
24 So in relative terms, handing an object from
25 one person to another is lower risk than talking

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1 face-to-face between an infected and noninfected
2 person.
3 Q. We talked before about, you know, people in
4 separate cars being very low risk. Is that risk,
5 from a public health perspective, an acceptable risk
6 from your standpoint, if it's a very low-risk
7 activity?
8 A. Mr. Wiest, I'm --
9 Q. Now --
10 A. Can you repeat it or rephrase it? I think I
11 understand it, but if you could repeat it or rephrase
12 it. I'm trying -- trying to give you an accurate
13 answer to this. And I want -- I want to be precise
14 in it because it's a good question, but I also want
15 to not have my answer be misunderstood.
16 Q. Yeah. At no time has the Governor or you
17 ever issued an order that says no one can drive in
18 automobiles because you might get close to someone
19 else. And I think, you know, at the heart of that is
20 a recognition that the risk is so low as to be
21 acceptable to allow people to drive in their
22 automobiles on the highway. Would you agree with
23 that?
24 A. Well, I would agree that it is a weighted
25 risk-versus-benefit analysis for these different

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1 recommendations. And in the case of driving in your
2 own automobile, the need for you to get from one
3 place to another to conduct your daily activities is,
4 is obviously important. And the relative risk
5 counterbalancing that of acquiring infection or
6 spreading it is, is very low. And so in that case
7 the analysis is not particularly difficult, it is one
8 where the evidence would clearly suggest that
9 driving, using your vehicle, is a reasonable
10 activity, weighing the risk versus the benefit.
11 Q. And, and to be fair, I -- would you agree
12 with me that when we -- as we go through these
13 orders, there is a cost-benefit that you and perhaps
14 others are performing in all of these orders? For
15 instance, restaurants, the benefit of having them
16 reopen perhaps from an economic perspective and other
17 perspectives warrants, you know, allowing that to
18 happen, subject to the 33 percent capacity.
19 In other words, as long as people keep under
20 that capacity of 33 percent and you're six feet away
21 from other people, the benefit outweighs the risks.
22 Would you agree?
23 MR. DUKE: I'm going to object to that
24 question once again on being outside of the scope of
25 the order.

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1 A. Okay. So I -- I would say that in any of
2 these decisions, I -- and when I offer my advice for
3 public health and safety, it is my intention to try
4 to keep people as safe as possible from a very
5 dangerous infection, the likes of which we've not
6 faced in a century.
7 This is an unprecedented challenge, that it
8 is a threat to humanity the world around. So we've
9 not had this in any of our living memories. And in
10 that calculus, I am appreciative of and cognizant of
11 the fact that there are very serious costs and
12 consequences that stem from these public health
13 measures. And, and those are not lost on me in their
14 general sense, and they weigh heavily on me
15 personally as I make these recommendations.
16 In making the recommendations, we are
17 attempting to reduce the risk to a level that
18 protects people as well as we are able while
19 permitting them to engage in these human interactions
20 that are otherwise important in, in their conduct of
21 their daily lives.
22 Q. Put another way, there -- there is a
23 cost-benefit analysis that you're engaging in as you
24 make these decisions; right?
25 A. In, in some --

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1 MR. DUKE: I'm going to object to that. I
2 don't know if that's a question; I think that's
3 testimony.
4 I think the question's been asked and
5 answered.
6 A. Each time I make these recommendations, I
7 try to weigh the pros and the cons, the risks and the
8 benefits, and the relative costs associated. And
9 recommend in balance what, what I feel is, is the
10 best balance I can achieve for public health safety
11 and, and other considerations.
14 Q. Thank you, Doctor. Let's look at Exhibit 9.
15 This is another order -- I'm going to get it up here
16 in a minute maybe.
17 Doctor, this was an order that you actually
18 issued a little bit before the last one on May 11th.
19 And this was an order that allowed, among other
20 things, office-based businesses -- or maybe it was
21 Secretary Friedlander that issued this. I think it
22 was. I don't think you actually signed this, but I
23 want to look just very, very briefly at the
24 office-based setting, if I can get down to it. There
25 we go.

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1 This had a restriction on it that provided
2 that not more than 50 percent of the employees be
3 physically present at the office any given day. Do
4 you see that?
5 A. I do.
6 Q. But there was no limit at all in terms of
7 the number of people that could be present in an
8 office setting where it couldn't otherwise be
9 avoided. And in that case it was the face masks and
10 six feet apart; right?
11 MR. DUKE: I'm going to object to that. I
12 will just -- my same objection as before, is that
13 these are not mass gatherings.
14 A. So in this context, there is not a specific
15 limit described there. Other documentation in force
16 at this time does describe that gatherings should be
17 kept to ten or fewer people. So there is other
18 guidance on the Healthy At Work website that
19 describes, for areas where there is not specific
20 description, that ten or less is the gathering max.
21 But in this context, yes, it does say -- and that one
22 bullet does not specifically limit it to any
23 percentage or specific number. It does, though,
24 require that there be face masks and the six feet
25 distancing between the individuals.

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3 Q. Okay. I want to look at -- we're going to
4 go look at Exhibit 10. Doctor, this was the -- I
5 know you -- I think you may have misspoken because
6 the, the order allowing ten people or more to -- or
7 ten or less to gather did not come in until May 20th;
8 right?
9 A. And I think --
10 MR. DUKE: I think that's --
11 A. Well -- yeah, I think you're correct. I
12 mean if that order preceded this, then you're
13 correct.
14 Q. Okay. And, and this was the order, and we
15 see it, ten people -- ten people or, or less are
16 allowed under this order; right?
17 A. Yes.
18 Q. Let me ask, Doctor, are you aware of any
19 case or study of -- evidence of COVID spreading from
20 the occupants of one car to another?
21 A. I am not.
22 Q. Okay. As we look at this order, I want to
23 go and look at page, go -- we're going to go down and
24 look at page 7, actually. Get there. Got it. Oh,
25 sorry. There it is.

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1 One of the things that you recommend is to
2 "hold the gathering outside whenever possible";
3 right?
4 A. Yes.
5 Q. And, and the reason -- I think we covered
6 this -- is because, all other things being equal,
7 outdoor gatherings are less risky than indoor
8 gatherings; correct?
9 A. Generally, yes.
10 Q. Okay. And again, this is the church
11 order -- or the church guidance has not changed,
12 either, since May 9th; is that fair?
13 A. I don't believe it has.
14 Q. Okay.
15 A. I'd have -- I'd have to look. As you'll
16 appreciate, my memory is, you know, has its limits
17 and there's a lot of activity taking place.
20 Q. No, I understand. And I'm trying -- I think
21 we're going to get you out of this deposition early
22 actually, Doctor, at the rate that we're going, so
23 that's good.
24 I want to look at Exhibit 11 very quickly.
25 Doctor, this was an order that you just issued, just

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1 about a week ago, on June 3rd, 2020. And I'll show
2 you -- that's your signature; right?
3 A. Yes, sir.
4 Q. And I specifically want to go down and look
5 at auctions; okay? And one of the things that this
6 says is if you cannot do it remotely, you have to do
7 it outside to the greatest extent practicable; right?
8 A. Yes.
9 Q. And again, the reason for that is, as we've
10 previously established, is that outdoor gatherings
11 are less risky, all other things being equal, than
12 indoor gatherings; right?
13 A. Yes.
14 Q. Now, there is a restriction on the number of
15 people, but only if it's done indoors. And in that
16 case, if it's done indoors, it's 33 percent of the
17 maximum permitted occupancy of the facility; right?
18 A. Yes.
19 Q. But for outside, it is six feet away from
20 each other and the auctioneers or staff; right?
21 A. That's what it says, yes.
22 Q. Okay. And when we're looking at outdoor
23 auctions, essentially as many people as they can fit
24 in the space are allowed to attend; right?
25 A. There is no upward limit stated in this

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1 document.
2 Q. Okay. And in an -- in an auction, the
3 auctioneer is speaking or yelling to the crowd as
4 he's soliciting bids; correct?
5 A. That's my understanding of an auction,
6 that's typically done, yes.
7 Q. And the crowd is bidding by yelling back
8 their bids; right?
9 A. Or raising a paddle or some other
10 methodology.
11 Q. Right. Yet there's no requirement that
12 they -- that they bid silently by paddle; right?
13 They're allowed to yell back at the auctioneer under
14 this order; correct?
15 A. This document does not specify it, I don't
16 believe.
17 Q. Okay. And the staff -- the staff are
18 required -- I'm going to show you it here in a
19 minute. The staff have to wear face masks or face
20 coverings if they're within six feet of someone else,
21 but there's no requirement that the crowd do so;
22 correct?
23 A. Well, it states that the auctions may
24 require customers to wear masks, but it does not
25 mandate that the auctions must enforce the customers

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1 to wear masks.
2 Q. And I just want to -- from a COVID risk
3 spreading perspective, there's no difference between
4 100 or, or let's just take a larger number -- 500
5 people at an auction or 500 people at a protest, is
6 there?
7 A. Well, those activities can be very different
8 from each other.
9 Q. Well, I'm going to ask you why in a second,
10 but in both cases people are shouting back and forth;
11 right?
12 A. Well, not to the same extent or in the same
13 nature.
14 Q. Again, I'm --
15 A. So I think -- I think that the, the
16 likenesses you're trying to draw, really it depends
17 on the individual activity itself.
18 Q. You're saying how the protest is conducted
19 or how the auction is conducted; right?
20 A. Well, correct. So, you know, as you've
21 talked about the different types of auctions,
22 thinking of a popular movie, Lara Croft: Tomb
23 Raider, where there's an auction scene right in the
24 movie and they raise paddles and no one speaks except
25 for the auctioneer. And the auctioneer is not

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1 shouting, the auctioneer is talking.
2 Q. Right.
3 A. So that auction is very different from the
4 type of auction we've already described as one
5 possibility. Just, just as other auctions or, or
6 protests can take different shapes and forms.
7 Q. Well, let's look at the worst-case auction
8 that's permitted under your order, Doctor.
9 Worst-case auction, we've got people shouting back
10 and forth at the auctioneer; right?
11 A. In one -- yeah, in worst-case scenario, I
12 guess you could have the entire attendance of the
13 auction shouting back at the auctioneer.
14 Q. Right. And, and in a worst-case protest,
15 you could have the entire protest shouting back and
16 forth, you know, with the protest leader; right?
17 A. You could.
18 Q. And in both cases, there may not be a good
19 way to ensure absolutely, perhaps, that, that social
20 distancing be enforced if the crowd is large enough;
21 right?
22 A. It could be that when you bring together
23 large numbers of people, it can be difficult to
24 enforce rules of any sort.
25 Q. Right. And there's no limit under this

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1 order in terms of the number of people that can
2 attend an outdoor auction; correct?
3 A. I can't see the whole order, but I'll just
4 say, yes, I -- I don't -- don't believe we specified
5 any upward max.
6 Q. There's no limit for the amount of time that
7 the outdoor auction can take place; correct?
8 A. Not in this document, there is not.
9 Q. All right. You previously, I think, were
10 going to -- and I want to allow you to answer the
11 question. How is this worst-case auction with a
12 large crowd any different than a -- than a protest?
13 A. So I -- again, I will have to give you
14 illustrative examples to demonstrate the various ways
15 they could be different.
16 Q. Yeah.
17 A. So --
18 Q. Yeah, and I want to focus in on the worst
19 case, where people are shouting back and forth in the
20 auction center.
21 A. I understand. If you are conducting an
22 auction, you often can have a way to record who's in
23 attendance. You may sell a ticket, you may know
24 who's present. You may have a way to identify or
25 locate or follow those people if there's a problem.

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1 If you are attending an auction, it is an organized
2 event in the sense that generally they can tell you
3 that these are the conditions under which you can
4 participate in the activity.
5 In fact, in this particular order it
6 empowers the, the organizer of the auction to exclude
7 people from participation if they -- if the auction
8 organizer requires masks and the individuals coming
9 don't choose to wear them, they can exclude those
10 individuals and decline to provide them that
11 activity.
12 That is -- again, it is not that a protest
13 could not be organized in similar fashion, but many
14 protests are not organized in such similar fashion.
15 There generally are not tickets sold, there are not
16 people who are recorded in person as to who is there
17 and who is not. The, the nature of the activity is,
18 has more informality in people coming and going, and
19 the intensity of passion, even though there are
20 intense auctions I am sure, is frequently not the
21 same across the events.
22 Which makes one event, meaning the auctions,
23 more likely to be amenable to control efforts. And
24 another event, meaning the, the protest or public
25 expression of opinion and that, that type of venue,

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1 more difficult and less likely to be controlled, or
2 control.
3 I will offer you a different example since
4 I've used a popular movie as one example. Watching
5 the television coverage just from this past weekend,
6 one can see the intensity of feeling people have
7 when, when expressing themselves in a protest about
8 deeply held beliefs. And then you can see examples
9 where individuals are embracing police officers with
10 neither person having a mask and close physical
11 contact occurring. In that setting, even with the
12 best of intentions, the nature of the activity lowers
13 the likelihood of compliance with rules set out in
14 advance.
15 Q. So as I understand what you're saying -- and
16 I'm going to go back and, and look at this -- there
17 is no requirement that an auction record who was
18 present under your orders; right?
19 A. Not in this specific order, but if you are
20 going to bid on an item, generally they have a way to
21 identify who you are, because if you successfully
22 secure the bid you have to pay for the bid you've
23 won.
24 Q. Sure. That, that is true. There's nothing
25 that keeps protestors from recording the protest

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1 itself and, in fact, you would agree in the age of
2 social media that often does, in fact, occur; right?
3 A. There's no prohibition about people taking
4 attendance at a protest. I'm not familiar that that
5 is the typical way in which protests are held. And I
6 -- and I would offer, Mr. Wiest, that the prohibition
7 is against mass gatherings, it's not specifically
8 against protests. The, the prohibitions have been
9 against people coming together in large volumes where
10 the risk of transmission of disease and infection is
11 markedly elevated.
12 Protests are only one of those forms, and
13 they are certainly not the only form of mass
14 gathering that is prohibited under these orders.
15 These, these other orders that you are showing with
16 me in these guidance documents, if you will, are
17 essentially exceptions to that rule where we are
18 attempting to permit activities that society has
19 expressed its need to engage in in a way that we have
20 tried to mitigate or reduce the risk as best we are
21 able to.
22 And as I no doubt think you've also
23 observed, that the condition continues to change as
24 we acquire more evidence, more scientific
25 understanding, and hopefully have some confidence

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1 that we are finding ways to control disease spread so
2 that we can permit the public to engage in as many
3 activities as possible with the least necessary risk
4 incurred.
5 Q. Okay. Have you made any recommendations to
6 the Governor in terms of permitting protest activity?
7 MR. DUKE: I'm going to object to that on
8 the grounds of executive privilege.
9 A. Am I still required to answer?
10 I have made recommendations only to the
11 general nature and extent of mass gatherings. The
12 extent that I have offered specific guidance is
13 embraced in these guidance documents where I have
14 made recommendations or -- and worked with teams of
15 individuals to recommend certain situations where
16 larger numbers of people may gather under these, you
17 know, specified conditions.
18 Q. And is there anything -- I guess let me ask
19 it a more simple way because this -- I think our
20 judge in the 6th Circuit is going to need the answer
21 to this. Is there anything in the works to permit
22 protest activities?
23 A. I don't have any specific guidance on a lot
24 of different types of activities, including protest
25 activities. The -- to give you the frame of

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1 reference, we have defined generally May to be the
2 phase one reopening, June to be the phase two. And,
3 and should we not experience a resurgence of disease
4 or, or overwhelming of the healthcare system, phase
5 three would begin on June 29th, at which point it is
6 our proposal to allow gatherings of up to 50 persons
7 and at which point we have received proposals for
8 various other activities. And if the proposals
9 fulfill the general nature of the guidance that we've
10 requested, we have, you know, granted acceptance for
11 some of those proposals after, you know, on or after
12 the date of June 29th.
13 Q. Doctor, you would agree with me that if a
14 protest activity occurs and someone were to encourage
15 the protestors to stand six feet apart and to wear
16 masks unless they're currently speaking, that would
17 be a far safer protest than if people are not doing
18 those activities; right?
19 A. Well, the only distinction I would give it
20 would be it's safer. I -- you, you've qualified it
21 with, you know, "far safer." It would be a -- it
22 would be a safer and a lower-risk environment if they
23 complied with the six feet distancing and the
24 universal mask.
25 Q. And would it be about on par with handling

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1 an outdoor auction in which people are speaking and
2 yelling back and forth in the context of conducting
3 an auction?
4 A. I don't know that I can give you that
5 because again we've, you know, I've tried to explore
6 how those different guide -- those different
7 situations are different, but I would say that to the
8 extent that mass gatherings occur, if people adhere
9 to the six-foot distance in all directions, wearing
10 masks, and also using proper hand hygiene, those --
11 those are considered to be three of the most
12 important measures we can advise to minimize the
13 spread of infection. I would say the nature of the
14 gathering -- or the purpose of the gathering, let's
15 say that, not the nature. The purpose of the
16 gathering, to me, is largely immaterial. It's the
17 nature of the gathering, how people interact with
18 each other at it.
19 Q. Okay. Just out of -- just curious. This is
20 the racetrack provision that was in the same order.
21 And apparently no media, no crowds are permitted
22 currently; right?
23 A. In the current order, yes.
24 Q. Okay. If -- and I'm just -- just curious.
25 If you were to allow that to occur but with

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1 distancing of six feet between customers, is that any
2 less risky or more risky than, than the auction?
3 A. Are you talking about if fans were
4 permitted?
5 Q. Yes, sir.
6 A. I would state -- and I will give you an
7 example now. There was a belief that Mardi Gras in
8 February in New Orleans where a million people
9 gathered in a largely outdoor environment was
10 considered to be a high risk for the spread of the
11 disease. And in 1918 when Philadelphia hosted a
12 parade in the middle of the Spanish influenza
13 epidemic, that has been well substantiated to have
14 been a super-spreading event increasing the risk of
15 transmission of disease.
16 So I would state that my general public
17 health preference would be to not have mass
18 gatherings of any sort for any reason, but that human
19 commerce and social engagements have been
20 counterbalancing pressures that have compelled us to
21 have to permit certain activities that are, while not
22 free of risk, we can try to take steps to recommend
23 interventions that will lower the risk.
24 So whether it be a space -- a space track --
25 I'm sorry -- a racetrack or whether it be an outdoor

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1 concert or whether it be a protest, for me, the fact
2 that we bring large numbers of people together during
3 a pandemic of -- caused by an infection for which we
4 have no vaccine, no cure, and no effective treatment,
5 are all risks that have to be balanced against the
6 competing benefit society is seeking to obtain from
7 them. And we will do our best to advise the public
8 about what those risks may or may not be and steps
9 they can take to mitigate those risks as best we and
10 they are able.
11 Q. So Doctor, I know that you -- I mean your,
12 your business is assessing the risk. Are you the one
13 who is also making the call on the value of a
14 particular activity or is that something that others
15 are also involved in?
16 A. I don't think I make a value determination
17 specifically on the activity. I make a determination
18 about the relevant risk of the activity itself. And,
19 and then in the decision of these things I make my
20 recommendations, and then others have multisource
21 input from other advisors that have to determine
22 where the relative risk and benefit weighting may
23 lie.

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1 Q. I want to look -- we're going to look at
2 some photos right now. And I think -- this is
3 Exhibit 12, and we're going to go through a bunch of
4 these. I will represent to you, although I think
5 you're going to recognize it, that these are a bunch
6 of photos of the Capital area, the lawn -- the lawn
7 area.
8 Doctor, you've been to the Capital; right?
9 A. A few times.
10 MR. DUKE: I want to object to the relevance
11 of this line of questioning. I think it's outside
12 the scope of the order.
13 MR. WIEST: It's going to be real relevant
14 in two questions.
15 MR. DUKE: I'll still lodge my objection.
16 MR. WIEST: No, I understand.
17 BY MR. WIEST:
18 Q. Doctor, you would agree with me that the
19 Capital itself is a -- there's a lot of open space
20 there; correct?
21 A. There's a fair amount of grassy, open space
22 at the Capital, yes.
23 Q. And I will tell you we got on the City of
24 Frankfort's GIS and we were able to measure square
25 feet about the front porch of about 201,851 square

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1 feet, and the back porch area of 68,946 square feet.
2 MR. DUKE: I'll lodge my same objection as
3 to the relevance of this question and ask that -- I
4 don't know how Dr. Stack can answer as to --
5 MR. WIEST: Well, yeah, I'm going to ask him
6 a hypothetical based off of it.
7 BY MR. WIEST:
8 Q. But Doctor --
9 MR. DUKE: Note my objection.
10 Q. -- you have no reason to quibble with those
11 square footage calculations; right?
12 A. I, I don't -- I don't dispute these but then
13 again, I also don't validate them --
14 Q. No, you --
15 A. -- so we can use them for the sake of your
16 discussion.
17 Q. Right. Would you agree with me that if
18 people were to stand in this 200 -- approximately
19 200,000-square-foot area, spread apart six feet
20 between households with masks on, that we could, you
21 know -- and assuming we could accommodate about a
22 thousand people doing that, is that a high-risk
23 activity or a low-risk activity, Doctor?
24 A. I would say, as I've said repeatedly
25 already, any time you bring large numbers of people

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1 together during the middle of a pandemic with an
2 easily spread infection for which we have no
3 successful intervention, it is a high-risk activity.
4 There are steps you can take to lower that risk or
5 mitigate the risk. In this instance being outdoors
6 is helpful, the fact that -- if you were to be able
7 to keep people six feet apart from each other, it's
8 helpful.
9 But it's also very possible you've contrived
10 a hypothetical that has no bearing on what the
11 likelihood of reality will be. In this case, if you
12 bring together people who are passionate, wildly
13 vocalizing on a topic, and moving around in a
14 free-flowing event, it is highly unlikely they will
15 stay in their six-square-foot box. And so I would
16 say that a mass gathering of any sort remains
17 undesirable in the middle of a pandemic. In this
18 particular case you are describing an activity that
19 is hypothetically possible but realistically
20 difficult, I think, to provide.
21 Q. You're saying the risk mitigation measures
22 of keeping people six feet apart may be difficult; is
23 that what -- is that correct?
24 A. Yes. And also when you're outdoors that
25 is -- that is helpful for lowering the risk of

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1 transmission of disease, but it is harmful to the
2 compliance with mask use given the heat of standing
3 out in the open sun and the discomfort associated
4 with wearing a mask under those conditions.
5 Q. Is sunlight an effective virus killer, do we
6 know?
7 A. There is evidence that ultraviolet radiation
8 decreases the duration where a virus will -- you
9 know, for which a virus is alive and, and, you know,
10 infective. So ultraviolet light is hopefully -- it's
11 felt to be generally helpful in lowering the duration
12 of time the virus will remain viable.
13 Q. And I take it that this is one of these
14 emerging areas of science that we don't have all the
15 answers on yet?
16 A. It is, because this particular virus has not
17 been around long enough for all the studies that will
18 be conducted. But, but in general viruses are less
19 durable, if you will, under the beating sunlight
20 because of the ultraviolet radiation.
23 Q. Okay. We're going to look at another
24 exhibit. Just issued this order. This was the June
25 8th order and specifically I am going down to page

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1 14. Oh, by the way, Doctor, that is your signature
2 on it; right?
3 A. Yes, sir.
4 Q. Okay. All right. This is the requirement
5 for libraries, distilleries, zoos, and wineries;
6 right?
7 MR. DUKE: I'd like to lodge my objection
8 right now as these -- those activities that were just
9 described are not mass gatherings and, therefore,
10 outside of the scope of the order.
11 Q. Well, let's talk about that. Doctor, you
12 would agree a mass gathering is anything that brings
13 together a group of people in a confined area -- over
14 ten people; right?
15 A. Mr. Wiest, that's an interesting question
16 because the federal guidance documents have described
17 various numbers. Groups of up to ten, groups of up
18 to 50, and groups of over 250. And there's this gap
19 between the 50 to 250. But by any measure, it is
20 felt that a gathering greater than 250 is a large
21 gathering. Some would call it a mass gathering.
22 Under 250 is still a large gathering.
23 And, and so there is some differences
24 just -- you know, judgment or definition in some of
25 those terms. But when you bring together groups of

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1 people larger than 250, I think most people would
2 consider that a large gathering. And, and quite a
3 few would also label it, in the middle of a pandemic,
4 as a mass gathering, though I recognize outside of a
5 pandemic that is not a terribly large gathering for
6 what people would normally do if there were not a
7 highly contagious pathogen spreading throughout the
8 community.
9 Q. And, and just to go back to the church
10 requirements of the, of the 33 percent building
11 capacity, we could easily get more than 250 people
12 inside, you know, some of the larger churches;
13 correct?
14 A. I think that's probably possible, yes.
15 Q. And looking at the auction environment, we
16 could easily get over 250 people attending an outdoor
17 auction; correct?
18 A. I can imagine that would not be difficult to
19 achieve in many settings.
20 Q. And so here we're looking at, for instance,
21 zoos. Let me ask, Doctor: Have you been to the
22 Louisville Zoo?
23 A. I have not.
24 Q. Have you been to the Lexington Zoo?
25 A. Do we have a Lexington Zoo?

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1 Q. Well, let me --
2 MR. DUKE: Hold on.
3 A. I'm not familiar that we have one.
4 Q. I've not been there. Let me -- let me just
5 back up. Zoos can fit over 250 people, can they not?
6 A. I -- yeah, I would believe most public zoos
7 could hold more than 250 people.
8 Q. Large public libraries can fit over 250
9 people; right?
10 A. Oh, I've seen libraries that can't, but
11 yeah, there's large -- large public library could
12 hold more than 250 people at its full, allowable
13 capacity, yes.
14 Q. Right. As the -- some of these others, the
15 Speed Museum, the Kentucky History Center, they can
16 fit over 250, can they not?
17 A. It should be a matter of fact. I mean I
18 don't -- if they can, they can. If they can't, they
19 can't. I just haven't been to all these places.
20 Q. Okay. Assuming that they can, the only
21 requirement that we've got is -- and let's go look,
22 it's six feet between households; right? Especially
23 for outdoors.
24 A. And they still have to follow the healthy
25 work guidance for gatherings of up to ten people.

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1 Q. Okay.
2 A. Which still require the masking, the
3 distancing, the hand hygiene, and, and other -- the
4 infection screening, I believe.
5 Q. Right. Okay. And then, you know, if
6 we're -- if we're indoor, you know, obviously what we
7 see indoor, I think -- let me go find it.
8 A. Mr. Wiest, while you're scrolling -- yeah,
9 stop -- stop right there real quick. And if you'll
10 see, because a number of these businesses have other
11 sub-businesses within them, they're required for
12 where it's relevant to follow the requirements for
13 restaurants or the requirements for retail
14 businesses. So a number of other documents are
15 incorporated by reference that require them for, say,
16 food concessions to adhere to the guidelines for
17 restaurants. So there are a number of layered
18 responsibilities in this guidance document not
19 specifically delineated within the document itself.
20 Q. Right. And so if they've got a snack bar at
21 the zoo, that snack bar has got to comply with the
22 restaurant requirements. If they've got a gift shop,
23 that's got to comply with the retail requirements;
24 right?
25 A. Yes, sir.

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1 Q. Okay. And I -- and really I'm just looking
2 at the zoo portion of it. Indoor -- if we've got an
3 indoor, now we're back to the 33 percent; correct?
4 A. In this document. I, I would offer for you,
5 since you've referenced the zoo multiple times, in
6 that instance the zoo offered a detailed plan itself
7 that very specifically identified its property and
8 the measures and steps that it would take.
9 Q. Okay. The -- let me -- let me ask, Doctor,
10 going back to the protests at the Capital, and I know
11 that the concern -- we talked about a thousand. What
12 if they had 250 people, or what if they had 200
13 people in that 200,000 square feet? Would that be a
14 problem if they were spread out?
15 A. Well, a much smaller gathering would, would
16 lower the risk if they were spread out, because there
17 -- and again, there's multiple things. And I'm sorry
18 to be repetitious, but in the interest of clarity --
19 but there's the density of the people, there's their
20 compliance with the other interventions, such as
21 not -- you know, not touching each other, and washing
22 their hands, sanitizing their hands, there's wearing
23 the masks.
24 Ideally there's not shouting, chanting,
25 screaming and things like that, because we've shown

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1 in, in -- very clear, repeatedly, the church setting
2 being the most common but there are others, that
3 people in choir practice held together for two and a
4 half hours singing, 87 percent of the people in that
5 choir practice over two and a half hours in Arkansas
6 were infected by COVID-19. So in those instances,
7 obviously there's risk of transmission.
8 And I've already explained, the larger the
9 group, the increased risk that there are more people
10 in that group who may have infection, expose others.
11 And I've used an analogy early in the course of this
12 response where I described it like buckshot where one
13 individual with infection exposes many others. And
14 when they disperse, they scatter and spread
15 infection, you know, to the places they go. But --
16 so in that context any gathering, again, represents a
17 potential risk. But as you described it, it would be
18 considered relatively less risk if you had 20 people
19 versus 200 versus 2,000 versus 20,000.
20 Q. Doctor, if there's a group of people on --
21 let's say it's lunch hour on the streets of
22 Louisville. It gets a little crowded down there
23 around lunch hour, and there's, you know, a thousand
24 people going to or from lunch; is that a risky
25 scenario if they're -- if they're spread out six feet

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1 apart?
2 MR. DUKE: I'll object. Calls for
3 speculation.
4 A. I would say people freely walking down a
5 city sidewalk close together still represents some
6 risk. But it represents directionally less risk
7 because they're probably not talking or engaging with
8 each other and they're just passing in transit. And
9 so in that case the duration of exposure between any
10 individual is, is low and, and likely to not be
11 particularly intimate or close.
12 Q. Okay.
13 A. I, I would say, Mr. Wiest, that will be -- a
14 different scenario would be standing on a packed
15 subway where people are in a narrow -- a closely
16 confined place with less air circulation and a dark,
17 air-conditioned environment for an extended period of
18 time. That would be the, the other extreme relative
19 or compared to someone passing casually on a crowded
20 street.
21 Q. Okay. And would, would something similar be
22 public transportation on buses in Louisville, to the
23 packed subway?
24 A. Well, I would say public -- they, they face
25 the same challenges.

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1 Q. Okay. We've not prohibited people from
2 using public transportation during this pandemic;
3 correct?
4 A. I don't think so.
7 Q. We have a couple more exhibits and, Doctor,
8 I promise you we're going to get you out of here
9 early. I think we're actually going to do that.
10 Let me share this one. Doctor, this is the
11 sports guidance. I realize this is not in effect
12 yet, although it is coming up. Let me ask: The, the
13 children -- one adult per groups of ten or, or less?
14 MR. DUKE: I'll object to the relevance.
15 MR. WIEST: Yeah, it's going to become
16 apparent real quick.
17 BY MR. WIEST:
18 Q. Let me ask, and there's no limit to the
19 number of groups that can -- that can attend that
20 outdoor practice; right?
21 A. Yeah, there's no limit stated here.
22 Q. Part of what goes on at sports practice is
23 the coach yelling; right?
24 A. That can happen at some -- at some sporting
25 events, yes, as far -- yes.

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1 Q. And, and part of what sometimes happens is,
2 is the student athletes can get kind of loud, too,
3 particularly at a practice; right?
4 A. That's a possibility.
5 Q. We don't limit how -- I realize they've got
6 to be within six feet, but the number of groups,
7 because we allow multiple groups to get together,
8 there's no limit to the number of kids that can
9 attend on a sports field or anything like that;
10 right?
11 A. Well, it says up there, see, when you talk
12 about social distancing, right above your
13 highlighter, the guidelines for groups of ten people
14 or fewer which require -- and that incorporates the
15 social distancing expectation of six feet or more,
16 masking, so that that's all incorporated in that
17 other document.
18 Q. Okay. Yeah, they are -- I know that there
19 is some masking requirements, but not while they're
20 actively practicing; right?
21 A. Right. So when -- when they're out on the
22 field, and for -- for many of these we've had to give
23 the acknowledgment that there are certain
24 circumstances where the counterbalancing risk is not
25 accept -- you know, means you can't do it. So we

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1 don't want people to be directly harmed wearing a
2 mask. And an instance is where perhaps standing in
3 85-degree heat wearing a mask is certainly -- could
4 represent a safety issue, that then we are not asking
5 people to endanger themselves directly to wear the
6 mask, which is why we have taken steps to try to
7 enforce social distancing as much as possible across
8 as many different settings as we are able.
9 Q. Okay. My son wanted me to ask you this:
10 Are we going to have a high school fall football
11 season, Doctor?
12 A. Can I protest myself and say we're -- calls
13 on speculation? I --
14 MR. DUKE: Yeah, I probably -- I'm going to
15 object but you, you can answer. Obviously I know
16 this is in jest, but --
17 A. Yeah. I don't know. Mr. Wiest, in any of
18 this it is my hope that we can -- our scientists and
19 medical experts will find some kind of vaccine,
20 treatment, or cure that will allow us to get back to
21 our normal activities as quickly as we can with the
22 least loss of human life and suffering possible so
23 that -- it's been very nice to meet you today in this
24 experience, but obviously if we were not in the
25 middle of a pandemic, you and I would not have had

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1 this opportunity.
2 Q. I appreciate that, Doctor. I've got a
3 couple more questions and then I think we're about
4 wrapped up.
5 MR. DUKE: And I'm going to have a few, few
6 on cross, too, Mr. Wiest.
10 BY MR. WIEST:
11 Q. I'm going to show you what we've marked as
12 Exhibit 15 maybe. All right. Dr. Stack, is this
13 activity in violation of the mass gatherings ban,
14 that's depicted in this photo?
15 MR. DUKE: Objection. Calls for speculation
16 and relevance.
17 A. So the collection of people in front there,
18 it is a large collection of -- and a public
19 collection of people that is currently prohibited
20 under the mass gathering guidance, yeah.
21 Q. Okay. And I'm going to show you a couple
22 more here in a minute, but is this activity that we
23 see going on in this photo endangering the public?
24 A. The gathering increases the risk of the
25 spread of the coronavirus.

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1 Q. Okay. Show you just a couple more.
2 A. And Mr. Wiest, scroll back up as long as
3 you're showing pictures here for me. One more.
4 Q. Yeah.
5 A. One more -- one more, I'm sorry. This one,
6 yeah.
7 You can visibly see in here an individual to
8 the left pulling his mask down on the left of my
9 screen.
10 Q. Right.
11 A. You see another individual to the right of
12 the screen not wearing a mask whatsoever, it doesn't
13 appear, or if it is, it's a bandana around their
14 neck. You can clearly see they're not within --
15 they're not outside of six feet together. Now, you
16 can also see others who are wearing a mask and who
17 are at least attempting to comply with that guidance.
18 I think these kinds of gatherings unfortunately are
19 just unpredictable in their nature and, and, you
20 know, that we would do our best to educate the public
21 about the risks and benefits of these types of
22 gatherings and, and then hope that we don't have
23 infection as a result.
24 Q. No, I understand. I have one more. Risky,
25 I take it, for people to be touching each other?

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1 MR. DUKE: Objection. Speculation.
2 A. Physical contact in the middle of a pandemic
3 is elevated risk.
4 Q. If -- if the people in this crowd -- and
5 I'll scroll back up. If, if they were wearing masks
6 and all standing six feet apart, would that be
7 acceptable?
8 A. I think -- so again, Mr. Wiest, not trying
9 to be difficult, but to answer your question,
10 bringing large numbers of people together in the
11 middle of a respiratory-transmitted pandemic is
12 undesirable even if we try to reduce the risk. If
13 these people were all to be standing six feet away
14 from each other, wearing masks, standing in the
15 outdoors, that would be a lower-risk gathering, but
16 it would not be a no-risk gathering.
17 And unfortunately, because there's a risk
18 that in such a large gathering there's almost
19 certainly some people who have the infection, in our
20 current knowledge of the state of infection in the
21 State of Kentucky. There is risk of transmission
22 because we've even seen that highly trained,
23 qualified healthcare professionals have difficulty
24 maintaining personal protective equipment hygiene,
25 just because it's difficult, let alone in the

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1 untrained, lay public. And so you can lower the
2 risk, which is what we are trying to do. And you've
3 described one theoretical way it could be lowered,
4 which would be everybody to be masked, six feet apart
5 from each other.
6 Q. Let me ask you, Doctor, can you quantify
7 that risk, the lowering if people were to be masked
8 and all standing six feet apart?
9 A. I -- I wish I could. I -- but I am not sure
10 that there's a mathematical model that would easily
11 allow me to do that. And I would say that each one
12 of those measures, if you're six feet apart -- and
13 we've already talked that typically we think we spray
14 respiratory particles from our mouth about three
15 feet. That adds a substantial margin of risk
16 reduction. Wearing a mask further enhances that.
17 And of course, you know, following those two things
18 alone in a large gathering like this would be
19 particularly helpful.
20 MR. WIEST: Okay. Let me make sure -- I
21 think I am -- let me make sure. I'm making sure Mr.
22 Bruns doesn't have, have anything for me.
23 Tom, you can jump in. Do you have anything
24 else?
25 MR. BRUNS: No.

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1 MR. WIEST: Okay. I tender the witness,
2 sir.
3 MR. DUKE: Could we take about a five or ten
4 minute recess before we go to cross?
6 MR. DUKE: Thank you.
7 MR. WIEST: We'll just all mute.
8 MR. DUKE: Yeah, and yeah.
9 (Brief recess.)
10 DIRECT EXAMINATION
11 BY MR. DUKE:
12 Q. Thank you. Okay. Dr. Stack, just a few
13 follow-up questions. Once again for the record, my
14 name is Wesley Duke. I just want to go back.
15 Now, you -- and I think we've clarified that
16 you're the commissioner of the Kentucky Department of
17 Public Health?
18 A. I am.
19 Q. Do you think that in your professional
20 opinion, that the provisions on mass gatherings that
21 were put into place in the March 19th order had a
22 real and substantial relationship to the public
23 health of the Commonwealth?
24 A. I do.
25 MR. WIEST: Object to form.

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1 Q. Would you like to -- and what did you base
2 this decision on -- these decisions on?
3 A. That the evidence in the early days of this
4 epidemic and at present show that when people are
5 brought together in densely confined areas, that the
6 risk of spreading the contagion is elevated. I
7 believe we saw this in Wuhan, China and Lombardy,
8 Italy, also here domestically in New York City.
9 And there were publications from the Centers
10 for Disease Control, the World Health Organization,
11 and others that identified that mass gatherings were
12 felt to be particularly high risk. And on the basis
13 of my observed experience -- or observing experience
14 in other parts of the world and reading from public
15 health experts in the form of WHO, CDC, and others,
16 it was felt by the public health community and myself
17 that large gatherings of people were particularly
18 high risk for spreading this dangerous infection.
19 Q. Based on your knowledge of the science as it
20 is evolving, has anything changed that position?
21 A. I still believe that mass gatherings are
22 elevated risk for spreading infections.
23 Q. Now, we had talked a lot of about different
24 activity and different actions. Would you consider a
25 trip to the grocery store to be a mass gathering?

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1 A. I do not because the nature of the trip to
2 the grocery store is fundamentally different. At
3 least in my experience, I have generally gone to the
4 grocery store, selected the items I desired off of
5 the shelf. Seldom do I speak to anybody during that
6 interaction. And then I reach the checkout, which is
7 nowadays often a self checkout, though not always,
8 and so I may not interact with other people in any
9 means except to pass them in a transitory nature, you
10 know, walking down an aisle.
11 Q. And on your -- and from your scientific
12 background and I guess your professional point of
13 view, how would you describe that difference between
14 a transitory experience and a communal experience?
15 A. So a transitory experience has individuals
16 who are only very briefly or temporarily near each
17 other. They often don't interact with each other
18 personally or directly. And I already said this, but
19 just to be clear, it's a brief interaction. So in --
20 in communal activities, and those could be any shape
21 or form where you're together with a group of people
22 over an extended period of time, you have extended
23 exposure to the same people, which increases the risk
24 if one or more of them have an infection, they may
25 spread it to you.

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1 Q. If the -- so is it safe to say the more
2 contact there is, the higher the risk of infection of
3 COVID-19?
4 A. Yes.
5 Q. And the more -- for example, the more
6 talking between -- or in the vicinity of parties?
7 A. Yes. The exposure -- duration of exposure
8 and intensity of exposure are both two different
9 variables. The duration of exposure is how long you
10 are in the same space or close proximity to someone
11 who has the infection. The, the intensity of the
12 exposure would be -- you know, kissing someone who
13 has coronavirus would be a particularly high risk way
14 to acquire the infection from someone with it.
15 Talking and shouting and singing, loud
16 vocalizations -- or coughing or sneezing are, are
17 other elevated risks, though clearly not to the same,
18 you know, magnitude as kissing someone.
19 Q. And those are, I guess to reiterate your
20 earlier testimony that those types of behavior, the
21 yelling, the shouting, the chanting, the singing, are
22 more likely to occur at a protest?
23 A. Well, I -- I would broaden it. I would say
24 that they're likely to occur -- more likely to occur
25 in a number of different settings. Places where

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1 people come together specifically to sing, I would
2 say are elevated risk. Where people come together at
3 a protest and they are shouting or chanting or
4 cheering, I would say that that's another situation
5 where there's elevated, you know, risk because you're
6 just -- you're projecting more respiratory droplets
7 with more force and for an extended period of time.
8 Q. And in your medical opinion -- we talked
9 about, about a trip to the zoo. Would you
10 characterize that as a transitory experience or a
11 gathering?
12 A. I would say for the participants in the
13 zoo -- again I have to rely on my own experience, I
14 -- Mr. Wiest, I have been to many zoos in my
15 lifetime, though I have not been to the Louisville
16 Zoo, but I will strive to correct that deficiency
17 since I'm a proud Kentuckian.
18 I would say that you interact with the
19 members of your own household probably fairly
20 significantly as you go through the experience, but
21 that your interaction with most other people, other
22 than the employees where you may buy food at a
23 concession stand or buy materials in a store, that
24 most of those engagements are transitory in -- just
25 in passing in an outdoor space usually, though there

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1 are clearly indoor exhibits in some of these zoos.
2 Q. And all of the advice and guidance that you
3 have given during the -- during the pandemic, or
4 since -- or since March 6th, since we've been under a
5 state of emergency, have those all been based on
6 basic public health principles and the science as you
7 know it?
8 A. Yes. I, I have used basic public health
9 knowledge and principles. And, in fact, this is
10 particularly foundational public health in
11 recommending these sorts of nonpharmaceutical
12 interventions, as they call them, which are public
13 health distancing measures.
14 Q. And none of your decisions have been based
15 on any personal value judgments or anything along
16 those lines?
17 A. No, sir. Other than that my, my goal is to
18 try to keep as many people safe as possible from this
19 infection.
20 MR. DUKE: I think that's all the questions
21 I have.
22 MR. WIEST: All right. I've got a few
23 follow-ups.
24 RECROSS-EXAMINATION
25 BY MR. WIEST:

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1 Q. Doctor, is a gathering in an office
2 conference room with 25 people a mass gathering?
3 MR. DUKE: Object to form.
4 A. Well, not by the definitions I told you,
5 because the, the guidelines that we're describing --
6 again, there, there is a subjective determination in
7 this based on just, you know, expert consensus, but
8 the cut points have been up to ten people, up to 50
9 people, and then gatherings over 50 or over 250. But
10 in that context, the gathering in a conference room
11 as you just described would be a gathering but not
12 described as a mass gathering.
13 Q. Would a hundred people at an outdoor auction
14 be a mass gathering?
15 A. It would be a large gathering. And I would
16 just -- I would just solve your, your questioning
17 here and just say anything over 250, I would say -- I
18 would call -- classify as a mass gathering in the
19 middle of a pandemic.
20 Q. And so 250 -- or let's say 300 people at an
21 auction, which is permitted in an outdoor auction,
22 that is a mass gathering; right?
23 A. I would have to say yes, that that is --
24 that is a type of a mass gathering.
25 Q. You talked a minute ago about communal and

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1 transitory activities. Is a communal activity --
2 would you say that 300 people at an outdoor auction
3 is a communal activity?
5 A. I, I would say that in the context that I
6 was describing it, I would say 300 people coming
7 together is both a mass gathering and, because they
8 are likely to be there for an extended period of
9 time, which is the way I was using communal in, in
10 part was -- that yes, it would be a communal mass
11 gathering.
12 Q. Is 300 people at a -- in a factory floor, is
13 that a mass gathering?
15 A. I would say that it is a, a large and a mass
16 gathering by the definition.
17 Q. Okay.
18 A. I would say that in my assessment of these
19 different circumstances though, and you'll recall
20 that I have identified that I'm trying to weigh risks
21 and benefits, we have in our guidance where we've
22 made these exceptions, identified circumstances where
23 we felt they were essential or life-sustaining
24 services.
25 And so for -- obviously I, I can't classify

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1 an auction as a life-sustaining or essential service,
2 but -- but factories, places generating energy,
3 places providing food and shelter, those would be
4 examples of areas where the counterbalancing human
5 need for the services provided has been a
6 consideration where, you know, under which we have
7 permitted activities we otherwise generally would not
8 have preferred to grant.
9 Q. And so there was a value judgment that those
10 life-sustaining activities needed to go on; correct?
12 A. So there was an attempt to weigh those --
13 those particular activities that were necessary that
14 support, you know, essential functions for human --
15 you know, regular human maintenance and survival.
16 Q. Right. When you -- when you say benefits of
17 life-sustaining activities, you're making a value
18 judgment that they need to continue to occur; right?
19 A. Mr. Wiest --
20 MR. DUKE: Objection. I'm going to object
21 to the form of that question.
22 A. Mr. Wiest, I'm going to strive to give you
23 an answer here, but when you say a value judgment,
24 I'm making a weighted risk-benefit analysis for, for
25 where there appear to be benefits that counterbalance

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1 the risks that are incurred because overall, like
2 I've said, I'm trying to reduce risk as much as
3 possible. And where risk has to be accepted, trying
4 to find instances where, where the reason for
5 accepting it is, is necessary to, you know, human
6 activity.
7 Q. Well, let me use a synonym of value.
8 Another synonym of value is, is something's
9 important.
10 You're determining that something -- that
11 life-sustaining activities are important enough to
12 where they have to continue to occur; right?
13 MR. DUKE: I'm going to -- objection. The
14 witness has, has answered the question.
15 MR. WIEST: He has not answered. If he
16 would, I'd move on.
17 A. Yeah, I would say that they are important
18 activities.
19 BY MR. WIEST:
20 Q. And you've determined that outdoor auctions
21 are important enough to continue to go on, even
22 though there's potentially large crowds and
23 potentially people shouting back and forth; correct?
24 MR. DUKE: Objection. Asked and answered.
25 A. All right. So Mr. Wiest, again, in that

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1 context I have tried to be as precise as I'm able to,
2 that there are complex analyses. So in that
3 environment, there's the possibility of constraining
4 variables more reliably than there are in other
5 situations.
6 And I -- and I do not purport to say that
7 each of these is without risk, but where we can
8 constrain variables to lower the risk as much as
9 reasonably possible, some of those activities are
10 being permitted as part of the phased reopening of
11 activities, which is, you know, in compliance with
12 the general guidelines outlined nationally.
13 And so those activities, an auction, were
14 not permitted in phase one. And now, as we are in
15 phase two and we enter phase three, those and other
16 activities will be permitted pursuant to certain
17 guidances to try to reduce risk in these increasingly
18 risky environments, outdoor activities being
19 permitted.
20 Q. Doctor, your orders don't ban, say, 50
21 people in a typical office environment from attending
22 a retirement party during working hours; right?
23 MR. DUKE: Objection. Form.
24 A. It, it does not ban that 50 people could get
25 together, to the best of my recollection. But it

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1 places significant restrictions. So, so common
2 gathering areas, cafeterias, communal areas, all of
3 those areas have been very explicitly in most of
4 these guidances declared to be undesirable, if not
5 strongly discouraged or prohibited. And people are
6 encouraged to not congregate in any area, you know,
7 within the building.
8 So I -- what I would say is you are correct,
9 we have not explicitly prohibited a gathering of up
10 to 50 people in an office environment, but we have
11 given substantial additional guidance as to how that
12 activity should occur if it is to occur.
13 Q. Okay. There would be nothing that would
14 keep you from giving guidance on -- and I know
15 California just did this, I'm not sure if you're
16 aware of it -- on conducting protest activities;
17 right?
18 A. Mr. Wiest, as we go forward to phase three,
19 in any of these phases it has not -- how to say this,
20 sir. We are going to -- as long as we don't have a
21 massive resurgence of infection, we are going to
22 permit progressively larger gatherings over time, of
23 which protest is just one form and shape. And at --
24 those are likely to be included in some future
25 guidance, if not by explicit inclusion then because

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1 they are part of a general order for how gatherings
2 of a certain size may occur and under what
3 situations.
4 Q. Let me ask: Right now, Doctor, the state of
5 affairs is that there's -- there's a ban on
6 gatherings of more than ten people unless it's in
7 some other activity that we've looked at, restaurants
8 perhaps or auctions and things like that; right?
9 That's the current state of affairs?
10 A. Yes, sir.
11 Q. When we look at the Capital lawn, the
12 200,000 square feet, if you had to put a number on
13 the number of people if they were to be spread out
14 that could safely gather there -- or maybe not
15 safely, but create a medium or a low risk, what
16 number would you put on it?
17 MR. DUKE: Objection. Calls for speculation
18 and I believe we -- I believe this was asked and
19 answered earlier.
20 A. So Mr. Wiest, I would say you could
21 obviously hold substantially more people in a space
22 like that with, with a six-foot perimeter around all
23 of them. So obviously that outdoor space could,
24 could hold people standing in their confined space, a
25 great deal many more than could happen in an office

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1 space or other confined area.
2 Q. Well, and Doctor, I'm just -- is it -- if
3 you -- if you were looking to a group of protestors
4 that said to you, Doctor, we would like to do this,
5 we recognize this is not a risk-free proposition --
6 MR. DUKE: Objection to form.
7 Q. We -- but we want to go and conduct a
8 protest in person at the Capital, tell us how to
9 minimize risk. We're going to distance, we're going
10 to wear masks. How many of us would make it a medium
11 or low risk proposition? What would your answer be?
12 A. My answer today would be that gatherings of
13 that sort are not permissible until June 29th or
14 later, when we enter phase three, because that has
15 been the general guidance we have given for other
16 gatherings. Now, after June 29th, as we give
17 additional guidance for some of these larger events,
18 that will help inform how others can, you know,
19 comply with and participate in ways that we are
20 hoping will mitigate risk.
21 But I have said repeatedly throughout our,
22 our meeting this afternoon that all of these
23 gatherings entail risk in the middle of a pandemic.
24 From a public health standpoint, which is the primary
25 lens, you know, that I try to weigh the advice that I

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1 offer in this, in this pandemic, they are not
2 desirable. And, and the best we can do is offer
3 guidance for how people can reduce the risk of
4 spreading contagion, and so we will continue to do
5 that.
6 The risks earlier in this -- the, the risk
7 of the disease has not reduced, unfortunately. But
8 the, the growing knowledge base is helping us
9 hopefully to gain more experience and tailor our
10 recommendations to permit more human activities in a
11 reduced-risk manner. So we -- it is clearly a very
12 steep learning curve with a pathogen we've never
13 experienced before.
14 Q. So in terms of -- and I realize, Doctor,
15 that, you know, we're not permitting it today, but in
16 terms of risk reduction, what you could offer today
17 is if, if these people are going to do it anyways and
18 violate the orders, for public health purposes, six
19 feet apart and wearing a mask is your recommendation
20 at this point?
21 MR. DUKE: Object to form.
22 A. Well, Mr. Wiest, my -- so my, my scope and
23 my role is public health. My recommendation is that
24 the activity not occur.
25 Q. Right.

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1 A. Others have different responsibilities in
2 society and will determine, you know, how and when
3 and where, you know, the activities are enforced or
4 not. And there is a lot of inputs that could go into
5 those decisions. But for my purposes, I would -- I
6 continue to recommend that large mass gatherings are
7 an elevated risk of spreading this infection and that
8 that is not in the best public health interest both
9 at the community level or at the individual level.
10 Q. Okay. And, and just to be clear, your
11 definition of large mass gatherings is the 250 or
12 more?
13 A. I'm, I'm using that by reference because
14 that's the federal documents, yes.
15 Q. Right. That comes from the CDC; right? It
16 defines large mass gatherings as 250 or more; right?
17 A. They've used that in a number of documents.
18 MR. WIEST: Okay. Let me just check, I may
19 be done. Let me just check. All right. Doctor, I'm
20 done.
21 THE WITNESS: Thank you, Mr. Wiest.
22 MR. DUKE: I have one -- I've got one
23 follow-up, one or two follow-ups, Chris, if you'll
24 let me. I think just to clear something up, if you
25 don't mind.

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1 MR. WIEST: Yeah.
2 REDIRECT EXAMINATION
3 BY MR. DUKE:
4 Q. Dr. Stack, there is a -- there, there have
5 been certain industries and businesses that have been
6 designated as critical by the federal government; is
7 that correct?
8 A. There is actually a, an explicit list that
9 an agency of the federal government has defined and
10 which is referenced in our documents. I can't
11 remember the agency, but it is -- it is publicly
12 available, that describes essential infrastructure
13 and businesses, yes.
14 Q. And that list was taken into consideration
15 and played a part in all of our documents?
16 A. Yes. I, I personally looked at it, though I
17 can't recall the detail, but I looked at it as part
18 of this.
19 MR. DUKE: That's all I have.
20 FURTHER CROSS-EXAMINATION
21 BY MR. WIEST:
22 Q. Doctor, just to clarify, you're talking
23 about the CISA, critical infrastructure sector list?
24 A. Yes, sir.
25 Q. Okay.

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1 A. The, the document and that work product,
2 yes.
3 MR. WIEST: Okay. That's all I've got.
4 MR. DUKE: Thank you all.
5 MR. WIEST: Are you reading? You've got to
6 tell the court reporter, are you guys going to read?
7 MR. DUKE: Pardon?
8 MR. WIEST: Are you guys going to read?
9 MR. DUKE: No. We'll --
10 MR. WIEST: Okay.
11 MR. DUKE: Video's fine.
12 MR. WIEST: We're done.
13
14 (Witness excused.)
15 (Deposition concluded at 4:36 p.m.)
16
17
18
19
(SIGNATURE WAIVED.)
20 ____________________________ _______
21 STEVEN STACK, M.D. DATE
22
23
24
25

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1 )
COMMONWEALTH OF KENTUCKY )
2 )
3
4 I, Lee Ann Goff, Notary Public in and for the
5 Commonwealth of Kentucky, do hereby certify:
6 That the witness named in the deposition,
7 prior to being examined, was by me duly sworn;
8 That said deposition was taken before me at
9 the time and place therein set forth and was taken down
10 by me in shorthand and thereafter transcribed into
11 typewriting under my direction and supervision;
12 That said deposition is a true record of the
13 testimony given by the witness and of all objections
14 made at the time of the examination.
15 I further certify that I am neither counsel
16 for nor related to any party to said action, nor in any
17 way interested in the outcome thereof.
18 IN WITNESS WHEREOF I have subscribed my name
19 and affixed my seal this 15th day of June, 2020.
20
21 ________________________
22 Lee Ann Goff
23 Notary Public 580909
24
25 My Commission Expires: 7/1/21

(859) 261-8440
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Respiratory Medicine
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A study on infectivity of asymptomatic SARS-CoV-2 carriers

Ming Gao a, 1, Lihui Yang b, 1, Xuefu Chen c, Yiyu Deng d, Shifang Yang e, Hanyi Xu e,
Zixing Chen e, Xinglin Gao e, *
a
The Second School of Clinical Medicine, Southern Medical University, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou,
510515, China
b
Hospital Infection Control Division, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, China
c
Department of Infectious Disease, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, China
d
Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, School of Medicine, South China University of Technology, Guangzhou, 510080,
China
e
Department of Respiratory and Critical Care Medicine, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangdong Provincial
Geriatrics Institute, Guangzhou, 510080, China
A R T I C L E I N F O A B S T R A C T
Keywords: Background: An ongoing outbreak of coronavirus disease 2019 (COVID-19) has spread around the world. It is
SARS-CoV-2 debatable whether asymptomatic COVID-19 virus carriers are contagious. We report here a case of the asymp
Asymptomatic carrier tomatic patient and present clinical characteristics of 455 contacts, which aims to study the infectivity of
Contacts
asymptomatic carriers.
Infectivity
Material and methods: 455 contacts who were exposed to the asymptomatic COVID-19 virus carrier became the
subjects of our research. They were divided into three groups: 35 patients, 196 family members and 224 hospital
staffs. We extracted their epidemiological information, clinical records, auxiliary examination results and ther
apeutic schedules.
Results: The median contact time for patients was four days and that for family members was five days. Car
diovascular disease accounted for 25% among original diseases of patients. Apart from hospital staffs, both
patients and family members were isolated medically. During the quarantine, seven patients plus one family
member appeared new respiratory symptoms, where fever was the most common one. The blood counts in most
contacts were within a normal range. All CT images showed no sign of COVID-19 infection. No severe acute
respiratory syndrome coronavirus 2 (SARS-CoV-2) infections was detected in 455 contacts by nucleic acid test.
Conclusion: In summary, all the 455 contacts were excluded from SARS-CoV-2 infection and we conclude that the
infectivity of some asymptomatic SARS-CoV-2 carriers might be weak.
1. Introdution globally [4].

It has been proved that the pathogen of COVID-19 is severe acute
The emergence of the coronavirus disease 2019 (COVID-19) since respiratory syndrome coronavirus 2 (SARS-CoV-2), which has high ho
early December 2019, has spread to many countries recently and mology with SARS-CoV [5]. Similar to SARS-CoV, the dominant
sparked world pandemic via mass gathering [1–3]. As of March 24, SARS-CoV-2 transmission mode is human-to-human transmission [6].
2020, there have been 334981 confirmed cases and 14652 deaths Differently, the reproductive number (R0) (the expected number of
Abbreviations: COVID-19, Coronavirus disease 2019; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2; CHD, congenital heart disease; EDOU,
emergency department observation unit; ED, emergency department; CT, computed tomography; RT-PCR, Reverse Transcription-Polymerase Chain Reaction; GCDC,
Guangzhou Center for Disease Control and Prevention; CDC, Chinese Center for Disease Control and Prevention; IQR, interquartile ranges; PPE, personal protective
equipment.
* Corresponding author. Department of Respiratory and Critical Care Medicine, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences,
Guangdong Provincial Geriatrics Institute, 106 Zhongshan Er Road, Guangzhou, 510080, China.
E-mail addresses: [email protected] (M. Gao), [email protected] (L. Yang), [email protected] (X. Chen), [email protected] (Y. Deng),
[email protected] (S. Yang), [email protected] (H. Xu), [email protected] (Z. Chen), [email protected] (X. Gao).
1
Ming Gao and Lihui Yang contributed equally to this manuscript.
https://doi.org/10.1016/j.rmed.2020.106026
Received 25 April 2020; Received in revised form 11 May 2020; Accepted 12 May 2020
Available online 13 May 2020
0954-6111/© 2020 Elsevier Ltd. All rights reserved.
M. Gao et al. Respiratory Medicine 169 (2020) 106026
secondary cases produced by a single infected person in a susceptible with before (Fig. 1. b, d).
population) is estimated between two and three, which is higher than Meanwhile, nucleic acid tests by real-time RT-PCR assay were per
SARS [6,7]. Furthermore, the transmission of SARS occurs during the formed repeatedly. Nucleic acid tests were positive for five consecutive
symptomatic period [8]. For COVID-19, numerous asymptomatic in days from February 11 to 15. The results of the test on quarantine day 16
fections were found among close contacts of confirmed patients, like the (February 26) turned negative, subsequently, on quarantine day 18 and
report on “Diamond Princess” [9]. However, the epidemiological sig 20, which were also negative. She was then released from quarantine on
nificance of asymptomatic infections is unclear until now. Recent studies day 21 (March 2, 2020). Due to only laboratory-confirmed positive, case
indicated that transmission of COVID-19 could also occur from these A was diagnosed as an asymptomatic carrier, manifested by Guangzhou
individuals with no symptoms [10,11]. However, for now, whether Center for Disease Control and Prevention (GCDC).
asymptomatic SARS-CoV-2 carriers are contagious still remain
controversial. 2. Materials and methods
Here, we report a case of an asymptomatic SARS-CoV-2 carrier with
nosocomial infection, as shown below, and describe the clinical char 2.1. Study design and subjects
acteristics of 455 contacts. Our purpose is to analyze the infectivity of
asymptomatic carriers. In our study, asymptomatic COVID-19 carrier was defined as a pa
Case A was a 22-year-old female patient who had a medical history of tient without related clinical symptoms, but whose SARS-CoV-2 test was
congenital heart disease (CHD) presented to the emergency room of positive. Since Case A was diagnosed, all contacts, including hospital
Guangdong Provincial People’s Hospital (Guangzhou, Guangdong staffs, family members and patients, were routinely screened. Amount
province, China) on January 13, 2020. She complained of shortness of ing to 455 contacts – 224 hospital staffs, 196 family members and 35
breath for 16 years, and the symptom worsened for one month. The patients – who had been exposed to case A in EDOU or circulated area of
accompanied symptom was chest distress, without cough, sputum pro it became the subjects of study. Contacts were defined as individuals in
duction and fever. Apart from CHD, she had no other diseases and had the same ward with Case A. EDOU plus the circulated area of it covers 60
no smoking habit. Her temperature was normal, and laboratory mea square meters where there are 14 patients’ beds placed at least 1.2 m
surements showed no apparent abnormalities (Table 1). Echocardiog apart. The study was approved by the Medical Ethical Committee of
raphy displayed atrial septal defect and severe pulmonary hypertension. Guangdong Provincial People’s Hospital.
The diagnosis was congenital heart disease, atrial septal defect and
pulmonary hypertension. 2.2. Data collection
Case A was mainly given to oxygen therapy, diuretic treatment, plus
pharmacotherapy of pulmonary hypertension. On January 16, as Case Isolated individuals’ detailed information during the emergency
A’s condition improved and vital signs became stable, she was trans department (ED) and hospitalization were retrospectively collected
ferred to emergency department observation unit (EDOU). Owing to the from electronic medical records, while other data were reviewed from
Spring Festival and COVID-19 outbreak, she had been hospitalized in documents recorded by related departments. Emphatically, we gathered
EDOU along with her brother until February 11. Before admission, she their contact history, consisting of the date when they went to the
underwent a serious of examinations according to hospital-formulated emergency, the reason why they came to the emergency, and the time
guidance during epidemic period. Nevertheless, the patient’s nasopha how long they were exposed to the case A. Demographics characteristics
ryngeal swab tested positive for SARS-CoV-2 by real-time Reverse were also collected.
Transcription-Polymerase Chain Reaction (RT-PCR). She was immedi Any new symptoms on each person were taken down, both in ED and
ately admitted to quarantine ward in infectious department. quarantine, including fever, cough, sputum production, sore throat, etc.
Case A and her brother both denied visiting Wuhan (the epidemic Meanwhile, we obtained imaging and laboratory data from hospital
area in China) and any contact with COVID-19 patients. They wore staffs and patients, which of family members were not noted. Each of
masks all the time except at meals and drinking. How she became patients had undergone a CT scan prior to admission because of the
infected was unknown. outbreak. It had been reviewed after the medical isolation began. Hos
Notably, in isolation, the patient had never fever, sore throat, pital staffs were examined one time. For laboratory test, a complete
myalgia or other symptoms associated with virus infection [12]. blood count was focus of attention. Nasopharyngeal swab specimens had
Shortness of breath and chest distress, without further aggravation than been collected at least one time in whole people. All samples were
before, were thought to be caused by CHD. Laboratory measurements processed at clinical laboratory of hospital and sent to GCDC
reflected that white blood cells, lymphocytes, C-reactive protein and simultaneously.
procalcitonin were within a normal range (Table 1). Upon admission, Patients and family members were quarantined for medical obser
chest computed tomography (CT) scan showed non- COVID-19 imaging vation and hospital staffs were not quarantined because of standard
feature (Fig. 1. a, c). In the time of hospitalization, the patient received protection, in principle.
antiviral and interferon therapy. 11 days after the treatment (February
22), chest CT scan indicated no significant differences in comparison 2.3. Laboratory nucleic acid test
In accordance with the protocol announced previously by the WHO,

Table 1 RT-PCR can be considered in the assessment of individuals who have
Laboratory measurements of Case A.
had contact with a COVID-19 case [13]. Consequently, whether the
Jan, 13 Feb, 12 Feb, 19 Feb, 27 Normal range patients were infected with the SARS-CoV-2 was detected by real-time
Blood count, � 10⁹/L RT-PCR. Chinese Center for Disease Control and Prevention (CDC)
White blood cell count 7.70 7.78 7.41 7.92 3.50–9.50 published the sequences of primers and probe targeted to envelope gene
Neutrophil count 4.97 4.14 4.16 4.44 1.80–6.30 of SARS-CoV-2, in January 21, 2020, which were as follows: forward
Lymphocyte count 2.13 2.91 2.13 2.63 1.10–3.20
primer 50 -TCAGAATGCCAATCTCCCCAAC-30 ; reverse primer 50 -AAAG
Serological variables
C-reactive protein, mg/L 0.6 5.89 NT NT ＜5.0 GTCCACCCGATACATTGA-30 ; and probe 50 CY5CTAGTTACACTAGC-
Procalcitonin, ng/ml Normal Normal NT NT ＜0.05 1CATCCTTACTGC-30 BHQ1.
NT ¼ not tested.
2
Fig. 1. Chest CT images of Case A. Figure a and c were taken on February 11, which showed non- COVID-19 imaging feature. Case A underwent a CT scan again on
February 22. Figure b and d, the follow-up images, showed no significant differences than before.
2.4. Statistical analysis lymphoblastic leukemia. Besides one patient, died on quarantine 4-day,
34 patients underwent multiple nucleic acid tests of SARS-CoV-2. All the
All research objects employed fundamental descriptive analysis. results were negative, including first time of the dead. Of 35 patients
Continuous variables were expressed as the medians and interquartile that had more than once chest CT scan, CT abnormalities were reported
ranges (IQR). Categorical variables in each category were summarized in 68.6%. The most common manifestations were inflammatory change
as counts and percentages. All statistical analyses were conducted with (34.3%) and pleural effusion (45.7%). The interstitial change was
IBM SPSS statistics 24.0. detected less. Pulmonary edema and nodule were seen in persons with
heart failure and lung cancer, respectively. Of particular concern, all CT
3. Results findings were non-viral infection discussed professionally by radiolo
gists. Normal CT image was found in 11 of 35 patients (31.4%).
3.1. Patients According to evaluation from physicians, there were 19 infected
patients (54.3%). Of these 19 patients, 15 (42.9%) had pneumonia,
The statistics of 35 patients are displayed in Table 2. All patients also which was bacterial (37.1%), followed by pendulous (2.9%) and aspi
wore masks except for eating or drinking and were admitted to infec ration (2.9%). Mediastina inflammatory and abdominal infection arose
tious department for medical isolation. The median contact time was from two patients with fistula. Other two patients had suffered from
four days (interquartile range, 1.0 to 6.0), whereas the longest among infection due to protopathy on admission. Above infected patients were
them reached 21 days. The median age of the patients was 62 years administered for empirical antibiotic treatment. Four (11.4%) patients
(interquartile range, 50.0 to 84.0). A total of 57.1% were males. All needed emergency surgery for their condition. The rest of them (34.3%)
individuals had been to ED of our hospital for various diseases. Un were received to heteropathy.
doubtedly, acute cardiovascular event and digestive diseases were It totally took 14 days from the last contact with Case A to the end of
common, accounting for 25.7% and 22.9%, respectively. medical observation. As of Feb 26, 2020, none of 35 patients was
In terms of clinical symptoms, 16 (45.7%) patients were free of diagnosed with SARS-CoV-2 infection. Among whom eight (22.9%)
respiratory symptoms, which more than half of them (19 [54.3%]) were discharged from the hospital while 25 (71.4%) were transferred to
appeared inversely. The respiratory symptoms involved fever (11 the specialized department for further treatments. The remaining two
[31.4%]), cough (8 [22.9%]), dyspnea (7 [20.0%]) and sputum (4 individuals both died for severe heart failure judged by the clinical
[11.4%]). Among patients with fever, hyperthermia (body temperature expert panel during the period of quarantine.
>39 � C) occurred in one patient with chills after chemotherapy. Three
individuals presented slight fever (body temperature between 37.3 � C
3.2. Family members
and 38.0 � C), of whom temperature could return to normal without
therapy. Two individuals were diagnosed with infective endocarditis
In total, 196 family members were enrolled. The situation on wear
and acute pancreatitis severally with the cause of their symptoms
ing masks was the same as that in patients. Local CDC took charge of
including fever plus dyspnea and stomachache. Another five patients
following up 172 among them, who were ruled out SARS-CoV-2 infec
developed fever was consider as complication of the original disease,
tion after 14-days medical isolation, as far as we know. The rest of the
mostly pulmonary infection, whether the symptom was new or persis
escorts were placed in designated locations by GCDC for quarantine. Of
tent. Last but not least, all dyspnea was associated with heart failure.
these 24 escorts, 11 were male and 13 were female. They aged from 24
The blood counts in most patients were within normal range. Lym
to 86 years old and the median age was 47.5 years old (interquartile
phocytopenia (<1.5 � 109 cells/L) had appeared in 34.3% of the pa
range, 34.0 to 57.0). The median contact time was five days (inter
tients and leukopenia (<4.0 � 109 cells/L) in 8.6%. One patient was also
quartile range, 1.0 to 11.0). Regarding examinations, at least two
accompanied with neutropenia (<1.8 � 109 cells/L) on account of
nucleic acid tests were negative. All the attendants except a family
myelosuppression after chemotherapy. On the contrary, lymphocytosis
member had no respiratory symptoms in the time of quarantine. Details
(＞3.5 � 109 cells/L) was observed in a patient with acute
as below.
3
Table 2 Table 3
Clinical characteristics of 35 patients. Clinical characteristics of 224 hospital staffs.
Clinical characteristics Patients (n ¼ 35) Clinical characteristics Hospital staffs
(n ¼ 224)
Demographics characteristics
Age, median (IQR), years. 62 (50.0–84.0) Demographics characteristics
Male, sex, No. (%) 20 (57.1) Identity, No. (%)
Times of contact with Case A, median (IQR), days 4 (1.0–6.0) Doctor 59 (26.3)
Protopathy, No. (%) Nurse 101 (45.1)
Cardiovascular disease 9 (25.7) Others1 64 (28.6)
Digestive diseases 8 (22.9) Age, median (IQR), yr. 35 (28.0–42.0)
Cerebrovascular disease 5 (14.3) Male, sex, No. (%) 103 (46.0)
Orthopedic disease 4 (11.4) Respiratory symptoms
Hematological disease 2 (5.7) None, No. (%) 224 (100.0)
Renal disease 2 (5.7) Laboratory findings
Cancer 3 (8.6) Leukocyte count ( � 109/L, normal range 4.0–10.0), No. (%)
Others1 2 (5.7) Increased 29 (12.9)
Respiratory symptoms Decreased 0 (0.0)
None, No. (%) 16 (45.7) Normal 195 (87.1)
Any, No. (%) 19 (54.3) Lymphocyte count ( � 109/L, normal range 1.5–3.5), No. (%)
Fever 11 (31.4) Increased 5 (2.2)
Newly emerged fever 7 (20.0) Decreased 3 (1.3)
Cough 8 (22.9) Normal 216 (96.5)
Sputum 4 (11.4) Nucleic acid test negative, No. (%) 224 (100.0)
Dyspnea 7 (20.0) Radiologic findings
Newly emerged dyspnea 1 (2.9) Normal on chest CT, No./total No. (%) 171/223 (76.7)
Laboratory findings Abnormalities on chest CT, No./total No. (%) 52/223 (23.3)
Leukocyte count ( � 109/L, normal range 4.0–10.0), No. (%) Pulmonary nodule 29/223 (13.0)
Increased 14 (40.0) Pulmonary fibrosis focus 18/223 (8.1)
Decreased 3 (8.6) Pulmonary emphysema 5/223 (2.2)
Normal 18 (51.4) Quarantine personnel, No. (%) 0 (0.0)
Lymphocyte count ( � 109/L, normal range 1.5–3.5), No. (%) 1
Increased 1 (2.9) Others include security guards, cleaners, transportation personnel, support
Decreased 12 (34.3) crew.
Normal 22 (62.9)
Nucleic acid test negative, No. (%) 35 (100.0)

years old. The median age was 35 years old (interquartile range, 28.0 to
Radiologic findings
Normal on chest CT, No. (%) 11 (31.4)
42.0). Most of them were emergency workers so that they had long
Abnormalities on chest CT, No. (%) 24 (68.6) exposure to confirmed case. Oppositely, some doctors in other de
Inflammatory change 12 (34.3) partments had a brief stay, approximately one to 2 h, because of
Pleural effusion 16 (45.7) emergency consultation. It is noteworthy that all personnel working in
Interstitial change 2 (5.7)
ED must take medical protection – namely, using N95 mask, putting on
Pulmonary edema 1 (2.9)
Pulmonary nodule 1 (2.9) isolation gown and wearing goggle.
Clinical outcome No respiratory symptoms were observed, either existing or emerging.
Transfer to specialized department, No. (%) 25 (71.4) Blood test results revealed normal leukocyte count in 87.1% and
Discharge from hospital, No. (%) 8 (22.9)
lymphocyte count in 96.5%. Lymphocyte counts were decreased in three
Death, No. (%) 2 (5.7)
staffs (1.3%) without leukopenia (<4.0 � 109 cells/L). A pregnant nurse
1
Others include urologic diseases and rheumatic disease. failed to accept a CT scan. A minority of hospital staffs (52 [23.3%])
found abnormalities in CT, where pulmonary nodule, fibrosis focus and
A 37-year-old woman, who had stayed in EDOU (February 7) for 10 h emphysema were seen. All hospital staffs were tested twice for SARS-
as relative, developed slight fever (the highest temperature was 37.5 � C), CoV-2 nucleic acid, and the results were negative, which was identical
dry cough and sore throat after six days (February 13). Then she was with the two groups mentioned above. In contrast to them, none of 224
presented to our hospital immediately. According to the investigation, hospital staffs required medical observation.
she had worn a mask during the hospital visit and had a history of
recurrent acute tonsillitis. After admission, her CT images and labora 4. Dissusion
tory measurements were normal. Additionally, she experienced four
SARS-CoV-2 nucleic acid tests successively, all of which were negative. In this study, we recorded in detail the hospitalized situation, diag
The case was given empirical antibiotic treatment since admission, and nostic procedure, inspection results, treatment plans and clinical
her symptoms disappeared afterwards. Based on clinical symptoms as outcome of an asymptomatic SARS-CoV-2 carrier who was laboratory
well as auxiliary examination results, she received a diagnosis of acute confirmation by RT-PCR assay, but without related symptoms and im
tonsillitis finally. On Fberuray 25, she recovered and was discharged aging changes in concert with previous reports [12,14]. Also, we
from the hospital. analyzed epidemiological and clinical data from 455 contacts who had
been exposed to the asymptomatic patient. All the 455 contacts were
3.3. Hospital staffs excluded from SARS-CoV-2 infection. Of the 231 quarantined people
(196 family members and 35 patients), 229 were removed from medical
To ensure safety, 224 hospital staffs who had come into contact with observation successfully and two died for severe heart failure. New or
Case A were screened. As is clearly shown in Table 3, their identities existing respiratory symptoms were almost appeared in patients, which
were mainly composed of doctors (59 [26.3%]) and nurses (101 were considered to be associated with their original disease or compli
[45.1%]). Others coexisted in the same room with Case A for work, such cations. A family member complaining of fever was diagnosed as acute
as security guards, cleaners, transportation personnel, etc. Of these 224 tonsillitis ultimately. Unlike COVID-19, normal blood count was found
staffs, 103 were male and 121 were female, with ages ranging 21–60 in most contacts [12,15]. All CT images showed no sign of COVID-19
4
infection. Unquestionably, all cases tested negative for SARS-CoV-2 interests or personal relationships that could have appeared to influence
nucleic acid. This fact illustrated that there had been no cases of infec the work reported in this paper.
tion in a relatively dense space.
Since the outbreak, our hospital has taken a series of effective pre CRediT authorship contribution statement
vention and control measures, which made a considerable effect on
preventing the spread in this case. Above all, medical staffs abide by the Ming Gao: Methodology, Data curation, Writing - original draft,
principle of graded protection strictly. For patients and attendants, each Writing - review & editing. Lihui Yang: Investigation, Data curation,
patient can only be accompanied by one attendant, and both need to Formal analysis, Writing - review & editing. Xuefu Chen: Resources.
wear personal protective equipment (PPE). Nevertheless, there is still a Yiyu Deng: Writing - review & editing. Shifang Yang: Writing - review
risk of transmission of COVID-19 under stringent measures. Primarily, & editing. Hanyi Xu: Resources. Zixing Chen: Resources. Xinglin Gao:
shortages of PPE were common in the early stages. Medical resources Conceptualization, Project administration, Supervision, Validation.
were supplied to healthcare workers priorly. Due to these factors, pa
tients and attendants can only wear one mask for a long time, resulting Acknowledgments
in its ineffective. Besides, we noticed that some patients and relatives
wore PPE incorrectly due to the lack of adequate training, which was We owe thanks to the staffs of Guangdong Provincial People’s Hos
also possible for hospital staffs. Last but not least, it is unavoidable to pital for gathering data in our study. We also acknowledge all the objects
take off mask while eating or drinking, which provides an opportunity to in this study and their family members.
spread the virus.
Considering all the mentioned factors, we suggest that there are more Appendix A. Supplementary data
important reasons for achieving “Zero infection”. As is well-known,
person-to-person transmission through respiratory droplets is the main Supplementary data to this article can be found online at https://doi.
route of COVID-19 transmission [6]. Earlier research revealed that the org/10.1016/j.rmed.2020.106026.
viral load of respiratory tract samples in an asymptomatic patient was
similar to that in the symptomatic patients [11]. However, a single References
sample is difficult to be representative. In the light of “Zero infection” for
this case, we venture to guess that the viral load of respiratory tract [1] F.X. Lescure, L. Bouadma, D. Nguyen, et al., Clinical and virological data of the first
cases of COVID-19 in Europe: a case series, Lancet Infect. Dis. 20 (2020), https://
samples in the asymptomatic patient might not be high. Moreover, doi.org/10.1016/S1473-3099(20)30200-0. Published Online March 27 2020.
although pathogenic nucleic acids can be detected in respiratory tract [2] A.A. Adalja, E. Toner, T.V. Inglesby, Priorities for the US Health Community
samples from asymptomatic carriers, the opportunity of transmission is Responding to COVID-19, JAMA, 2020, https://doi.org/10.1001/jama.2020.3413.
Published Online March 03 2020. Available at:.
less than that in symptomatic patient owing to the absence of the way [3] B. McCloskey, A. Zumla, G. Ippolito, et al., Mass gathering events and reducing
expelling pathogen via cough and sneezing. further global spread of COVID-19: a political and public health dilemma, Lancet
Based on the foregoing discussion, we conclude that the infectivity of 395 (2020) 1096–1099, https://doi.org/10.1016/S0140-6736(20)30681-4.
[4] World Health Organization, Coronavirus Disease (COVID-19) Outbreak, 2020.
some asymptomatic SARS-CoV-2 carriers might be weak. This finding Available at: https://www.who.int/emergencies/diseases/novel-coronavir
implicates that there is not needful to worry unduly for asymptomatic or us-2019.
mild patients during the ongoing COVID-19 pandemic. Furthermore, [5] R. Lu, X. Zhao, J. Li, et al., Genomic characterisation and epidemiology of 2019
novel coronavirus: implications for virus origins and receptor binding, Lancet 395
excessive virus nucleic acid detection is unnecessary, which can relieve
(2020) 565–574, https://doi.org/10.1016/S0140-6736(20)30251-8.
the pressure on public health resources. Under the development of [6] Y. Wang, Y. Wang, Chen Yan, et al., Unique epidemiological and clinical features of
epidemic circumstance, more and more public concerns on the the emerging 2019 novel coronavirus pneumonia (COVID-19) implicate special
increasing number of asymptomatic or mild patients hid in the com control measures, J. Med. Virol. 92 (6) (2020) 568–576, https://doi.org/10.1002/
jmv.25748. Published Online March 05 2020.
munity. However, combined with our results and the defense measures [7] C. Del Rio, P.N. Malani, COVID-19-New Insights on a Rapidly Changing Epidemic,
currently completed, we hope such worries are misplaced and we also JAMA, 2020, https://doi.org/10.1001/jama.2020.3072. Published Online
believe the world will win this battle certainly. February 28 2020. Available at:.
[8] G. Zeng, S.Y. Xie, Q. Li, et al., Infectivity of severe acute respiratory syndrome
The limitation of our study is that there is only one case and lack of during its incubation period, Biomed. Environ. Sci. 22 (6) (2009) 502–510, https://
detailed information on family members quarantined locally. Large- doi.org/10.1016/S0895-3988(10)60008-6.
scale multicenter studies are needed to verify our conclusion. Howev [9] Diamond princess (ship), Available at: https://en.wikipedia.org/wiki/Diamond_
Princess_, 2020 (ship).
er, both asymptomatic carrier and 455 contacts were admitted to and [10] Z. Hu, C. Song, C. Xu, et al., Clinical Characteristics of 24 Asymptomatic Infections
treated in designated places. Hence, the study results are representative with COVID-19 Screened Among Close Contacts in Nanjing, China. Sci China, Life
to some extent. Sci, 2020, https://doi.org/10.1007/s11427-020-1661-4. Published Online March
04 2020. Available at:.
[11] L. Zou, F. Ruan, M. Huang, et al., SARS-CoV-2 viral load in upper respiratory
5. Conlusions specimens of infected patients, N. Engl. J. Med. 382 (2020) 1177–1179. Available
at: https://doi.org/10.1056/NEJMc2001737.
[12] W.J. Guan, N.S. Zhong, Clinical characteristics of covid-19 in China, N. Engl. J.
Infectivity of some asymptomatic SARS-CoV-2 carriers might be
Med. (2020) 382, https://doi.org/10.1056/NEJMoa2002032.
weak. Effective prevention and control measures are helpful to prevent [13] World Health Organization, Corona-virus disease (COVID-19) technical guidance:
COVID-19 spread of asymptomatic carriers. The result of this study may laboratory testing for 2019-nCoV in humans, Available at: https://www.who.int/e
alleviate parts of the public concern about asymptomatic infected mergencies/diseases/novel-coronavirus-2019/technical-guidance/laboratory
-guidance.
people. [14] S. Salehi, A. Abedi, S. Balakrishnan, et al., Coronavirus disease 2019 (COVID-19): a
systematic review of imaging findings in 919 patients, AJR Am. J. Roentgenol.
Funding (2020) 1–7, https://doi.org/10.2214/AJR.20.23034.
[15] C. Huang, Y. Wang, X. Li, et al., Clinical features of patients infected with 2019
novel coronavirus in Wuhan, China, Lancet 395 (2020) 497–506, https://doi.org/
This work was supported by the Science and Technology Planning 10.1016/S0140-6736(20)301847.
Project of Guangdong Province (No. 2020B111111005).
Declaration of competing interest
The authors declare that they have no known competing financial
5
Open Access Research
A cluster randomised trial of cloth
BMJ Open: first published as 10.1136/bmjopen-2014-006577 on 22 April 2015. Downloaded from http://bmjopen.bmj.com/ on June 7, 2020 by guest. Protected by copyright.
masks compared with medical masks
in healthcare workers
C Raina MacIntyre,1 Holly Seale,1 Tham Chi Dung,2 Nguyen Tran Hien,2
Phan Thi Nga,2 Abrar Ahmad Chughtai,1 Bayzidur Rahman,1 Dominic E Dwyer,3
Quanyi Wang4
To cite: MacIntyre CR, ABSTRACT

Seale H, Dung TC, et al. Strengths and limitations of this study
Objective: The aim of this study was to compare the
A cluster randomised trial of
efficacy of cloth masks to medical masks in hospital ▪ The use of cloth masks is widespread around
cloth masks compared with
healthcare workers (HCWs). The null hypothesis is that the world, particularly in countries at high-risk
medical masks in healthcare
workers. BMJ Open 2015;5: there is no difference between medical masks and for emerging infections, but there have been no
e006577. doi:10.1136/ cloth masks. efficacy studies to underpin their use.
bmjopen-2014-006577 Setting: 14 secondary-level/tertiary-level hospitals in ▪ This study is large, a prospective randomised
Hanoi, Vietnam. clinical trial (RCT) and the first RCT ever con-
▸ Prepublication history for Participants: 1607 hospital HCWs aged ≥18 years ducted of cloth masks.
this paper is available online. working full-time in selected high-risk wards. ▪ The use of cloth masks are not addressed in
To view these files please Intervention: Hospital wards were randomised to: most guidelines for health care workers—this
visit the journal online medical masks, cloth masks or a control group study provides data to update guidelines.
(http://dx.doi.org/10.1136/ (usual practice, which included mask wearing). ▪ The control arm was ‘standard practice’, which
bmjopen-2014-006577). Participants used the mask on every shift for 4 comprised mask use in a high proportion of par-
consecutive weeks. ticipants. As such (without a no-mask control),
Received 9 September 2014
Main outcome measure: Clinical respiratory illness the finding of a much higher rate of infection in
Revised 25 March 2015
Accepted 26 March 2015 (CRI), influenza-like illness (ILI) and laboratory- the cloth mask arm could be interpreted as harm
confirmed respiratory virus infection. caused by cloth masks, efficacy of medical
Results: The rates of all infection outcomes were masks, or most likely a combination of both.
highest in the cloth mask arm, with the rate of ILI
statistically significantly higher in the cloth mask arm
(relative risk (RR)=13.00, 95% CI 1.69 to 100.07) INTRODUCTION
compared with the medical mask arm. Cloth masks The use of facemasks and respirators for the
also had significantly higher rates of ILI compared with protection of healthcare workers (HCWs)
the control arm. An analysis by mask use showed ILI has received renewed interest following the
(RR=6.64, 95% CI 1.45 to 28.65) and laboratory- 2009 influenza pandemic,1 and emerging
confirmed virus (RR=1.72, 95% CI 1.01 to 2.94) were
infectious diseases such as avian influenza,2
significantly higher in the cloth masks group compared
with the medical masks group. Penetration of cloth
Middle East respiratory syndrome corona-
masks by particles was almost 97% and medical virus (MERS-coronavirus)3 4 and Ebola
masks 44%. virus.5 Historically, various types of cloth/
Conclusions: This study is the first RCT of cloth cotton masks (referred to here after as ‘cloth
masks, and the results caution against the use of cloth masks’) have been used to protect HCWs.6
masks. This is an important finding to inform Disposable medical/surgical masks (referred
occupational health and safety. Moisture retention, to here after as ‘medical masks’) were intro-
reuse of cloth masks and poor filtration may result in duced into healthcare in the mid 19th
increased risk of infection. Further research is needed century, followed later by respirators.7
to inform the widespread use of cloth masks globally. Compared with other parts of the world, the
However, as a precautionary measure, cloth masks use of face masks is more prevalent in Asian
For numbered affiliations see should not be recommended for HCWs, particularly in
end of article. countries, such as China and Vietnam.8–11
high-risk situations, and guidelines need to be
updated.
In high resource settings, disposable
Trial registration number: Australian New Zealand medical masks and respirators have long
Correspondence to
Professor C Raina MacIntyre; Clinical Trials Registry: ACTRN12610000887077. since replaced the use of cloth masks in hos-
[email protected] pitals. Yet cloth masks remain widely used
MacIntyre CR, et al. BMJ Open 2015;5:e006577. doi:10.1136/bmjopen-2014-006577 1

Open Access
globally, including in Asian countries, which have histor- Hanoi, of which 16 agreed to participate. One hospital
ically been affected by emerging infectious diseases, as did not meet the eligibility criteria; therefore, 74 wards
well as in West Africa, in the context of shortages of per- in 15 hospitals were randomised. Following the random-
sonal protective equipment (PPE).12 13 It has been isation process, one hospital withdrew from the study
shown that medical research disproportionately favours because of a nosocomial outbreak of rubella.
diseases of wealthy countries, and there is a lack of Participants provided written informed consent prior
research on the health needs of poorer countries.14 to initiation of the trial.
Further, there is a lack of high-quality studies around the
use of facemasks and respirators in the healthcare
Randomisation
setting, with only four randomised clinical trials (RCTs)
Seventy-four wards (emergency, infectious/respiratory
to date.15 Despite widespread use, cloth masks are rarely
disease, intensive care and paediatrics) were selected as
mentioned in policy documents,16 and have never been
high-risk settings for occupational exposure to respira-
tested for efficacy in a RCT. Very few studies have been
tory infections. Cluster randomisation was used because
conducted around the clinical effectiveness of cloth
the outcome of interest was respiratory infectious dis-
masks, and most available studies are observational or in
eases, where prevention of one infection in an individual
vitro.6 Emerging infectious diseases are not constrained
can prevent a chain of subsequent transmission in
within geographical borders, so it is important for global
closed settings.8 9 Epi info V.6 was used to generate a
disease control that use of cloth masks be underpinned
randomisation allocation and 74 wards were randomly
by evidence. The aim of this study was to determine the
allocated to the interventions.
efficacy of cloth masks compared with medical masks in
From the eligible wards 1868 HCWs were approached
HCWs working in high-risk hospital wards, against the
to participate. After providing informed consent, 1607
prevention of respiratory infections.
participants were randomised by ward to three arms:
(1) medical masks at all times on their work shift; (2)
METHODS cloth masks at all times on shift or (3) control arm
A cluster-randomised trial of medical and cloth mask (standard practice, which may or may not include mask
use for HCWs was conducted in 14 hospitals in Hanoi, use). Standard practice was used as control because the
Vietnam. The trial started on the 3 March 2011, with IRB deemed it unethical to ask participants to not wear
rolling recruitment undertaken between 3 March 2011 a mask. We studied continuous mask use (defined as
and 10 March 2011. Participants were followed during wearing masks all the time during a work shift, except
the same calendar time for 4 weeks of facemasks use while in the toilet or during tea or lunch breaks)
and then one additional week for appearance of symp- because this reflects current practice in high-risk settings
toms. An invitation letter was sent to 32 hospitals in in Asia.8
Figure 1 Consort diagram of

recruitment and follow-up (HCWs,
healthcare workers).
2 MacIntyre CR, et al. BMJ Open 2015;5:e006577. doi:10.1136/bmjopen-2014-006577

Open Access
The laboratory results were blinded and laboratory Data collection and follow-up
testing was conducted in a blinded fashion. As facemask Data on sociodemographic, clinical and other potential
use is a visible intervention, clinical end points could confounding factors were collected at baseline.
not be blinded. Figure 1 outlines the recruitment and Participants were followed up daily for 4 weeks (active
randomisation process. intervention period), and for an extra week of standard
practice, in order to document incident infection after
incubation. Participants received a thermometer (trad-
Primary end points itional glass and mercury) to measure their temperature
There were three primary end points for this study, used in daily and at symptom onset. Daily diary cards were pro-
our previous mask RCTs:8 9 (1) Clinical respiratory illness vided to record number of hours worked and mask use,
(CRI), defined as two or more respiratory symptoms or estimated number of patient contacts (with/without ILI)
one respiratory symptom and a systemic symptom;17 and number/type of aerosol-generating procedures
(2) influenza-like illness (ILI), defined as fever ≥38°C plus (AGPs) conducted, such as suctioning of airways,
one respiratory symptom and (3) laboratory-confirmed sputum induction, endotracheal intubation and bron-
viral respiratory infection. Laboratory confirmation was by choscopy. Participants in the cloth mask and control
nucleic acid detection using multiplex reverse transcript- group (if they used cloth masks) were also asked to
ase PCR (RT-PCR) for 17 respiratory viruses: respiratory document the process used to clean their mask
syncytial virus (RSV) A and B, human metapneumovirus after use.
(hMPV), influenza A (H3N2), (H1N1)pdm09, influenza We also monitored compliance with mask use by a pre-
B, parainfluenza viruses 1–4, influenza C, rhinoviruses, viously validated self-reporting mechanism.8 Participants
severe acute respiratory syndrome (SARS) associated were contacted daily to identify incident cases of respira-
coronavirus (SARS-CoV), coronaviruses 229E, NL63, tory infection. If participants were symptomatic, swabs of
OC43 and HKU1, adenoviruses and human bocavirus both tonsils and the posterior pharyngeal wall were col-
(hBoV).18–23 Additional end points included compliance lected on the day of reporting.
with mask use, defined as using the mask during the shift
for 70% or more of work shift hours.9 HCWs were cate-
gorised as ‘compliant’ if the average use was equal or more Sample collection and laboratory testing
than 70% of the working time. HCW were categorised as Trained collectors used double rayon-tipped, plastic-
‘non-compliant’ if the average mask use was less than 70% shafted swabs to scratch tonsillar areas as well as the pos-
of the working time. terior pharyngeal wall of symptomatic participants.
Testing was conducted using RT-PCR applying published
methods.19–23 Viral RNA was extracted from each respira-
Eligibility tory specimen using the Viral RNA Mini kit (Qiagen,
Nurses or doctors aged ≥18 years working full-time were Germany), following the manufacturer’s instructions.
eligible. Exclusion criteria were: (1) Unable or refused The RNA extraction step was controlled by amplification
to consent; (2) Beards, long moustaches or long facial of a RNA house-keeping gene (amplify pGEM) using
hair stubble; (3) Current respiratory illness, rhinitis real-time RT-PCR. Only extracted samples with the house
and/or allergy. keeping gene detected by real-time RT-PCR were submit-
ted for multiplex RT-PCR for viruses.
The reverse transcription and PCRs were performed
Intervention in OneStep (Qiagen, Germany) to amplify viral target
Participants wore the mask on every shift for four con- genes, and then in five multiplex RT-PCR: RSVA/B,
secutive weeks. Participants in the medical mask arm influenza A/H3N2, A(H1N1) and B viruses, hMPV
were supplied with two masks daily for each 8 h shift, (reaction mix 1); parainfluenza viruses 1–4 (reaction
while participants in the cloth mask arm were provided mix 2); rhinoviruses, influenza C virus, SARS-CoV (reac-
with five masks in total for the study duration, which tion mix 3); coronaviruses OC43, 229E, NL63 and
they were asked to wash and rotate over the study HKU1 (reaction mix 4); and adenoviruses and hBoV
period. They were asked to wash cloth masks with soap (reaction mix 5), using a method published by others.18
and water every day after finishing the shifts. All samples with viruses detected by multiplex RT-PCR
Participants were supplied with written instructions on were confirmed by virus-specific mono nested or hemi-
how to clean their cloth masks. Masks used in the study nested PCR. Positive controls were prepared by in vitro
were locally manufactured medical (three layer, made of transcription to control amplification efficacy and
non-woven material) or cloth masks (two layer, made of monitor for false negatives, and included in all runs
cotton) commonly used in Vietnamese hospitals. The (except for NL63 and HKU1). Each run always included
control group was asked to continue with their normal two negatives to monitor amplification quality. Specimen
practices, which may or may not have included mask processing, RNA extraction, PCR amplification and PCR
wearing. Mask wearing was measured and documented product analyses were conducted in different rooms to
for all participants, including the control arm. avoid cross-contamination.19 20

Open Access
Filtration testing model, to estimate RR after adjusting for potential con-
The filtration performance of the cloth and medical founders. As we pooled data of participants from all
masks was tested according to the respiratory standard three arms and analysed by mask type, not trial arm, we
AS/NZS1716.24 The equipment used was a TSI 8110 did not adjust for clustering here. All statistical analyses
Filter tester. To test the filtration performance, the filter were conducted using STATA V.12.28
is challenged by a known concentration of sodium chlor- Owing to a very high level of mask use in the control
ide particles of a specified size range and at a defined arm, we were unable to determine whether the differ-
flow rate. The particle concentration is measured before ences between the medical and cloth mask arms were
and after adding the filter material and the relative due to a protective effect of medical masks or a detri-
filtration efficiency is calculated. We examined the mental effect of cloth masks. To assist in interpreting
performance of cloth masks compared with the per- the data, we compared rates of infection in the medical
formance levels—P1, P2 (=N95) and P3, as used for mask arm with rates observed in medical mask arms
assessment of all particulate filters for respiratory protec- from two previous RCTs,8 9 in which no efficacy of
tion. The 3M 9320 N95 and 3M Vflex 9105 N95 were medical masks could be demonstrated when compared
used to compare against the cloth and medical masks. with control or N95 respirators, recognising that sea-
sonal and geographic variation in virus activity affects
Sample size calculation the rates of exposure (and hence rates of infection out-
To obtain 80% power at two-sided 5% significance level comes) among HCWs. This analysis was possible because
for detecting a significant difference of attack rate the trial designs were similar and the same outcomes
between medical masks and cloth masks, and for a rate were measured in all three trials. The analysis was
of infection of 13% for cloth mask wearers compared carried out to determine if the observed results were
with 6% in medical mask wearers, we would need eight explained by a detrimental effect of cloth masks or a
clusters per arm and 530 participants in each arm, and protective effect of medical masks.
intracluster correlation coefficient (ICC) 0.027, obtained
from our previous study.8 The design effect (deff ) for
this cluster randomisation trial was 1.65 (deff=1+(m RESULTS
−1)×ICC=1+(25−1)×0.027=1.65). As such, we aimed to A total of 1607 HCWs were recruited into the study. The
recruit a sample size of 1600 participants from up to 15 participation rate was 86% (1607/1868). The average
hospitals. number of participants per ward was 23 and the mean
age was 36 years. On average, HCWs were in contact
Analysis with 36 patients per day during the trial period (range
Descriptive statistics were compared among intervention 0–661 patients per day, median 20 patients per day).
and control arms. Primary end points were analysed by The distribution of demographic variables was generally
intention to treat. We compared the event rates for the similar between arms (table 1). Figure 2 shows the
primary outcomes across study arms and calculated primary outcomes for each of the trial arms. The rates
p values from cluster-adjusted χ2 tests25 and ICC.25 26 We of CRI, ILI and laboratory-confirmed virus infections
also estimated relative risk (RR) after adjusting for clus- were lowest in the medical mask arm, followed by the
tering using a log-binomial model under generalised control arm, and highest in the cloth mask arm.
estimating equation (GEE) framework.27 We checked for Table 2 shows the intention-to-treat analysis. The rate
variables which were unequally distributed across arms, of CRI was highest in the cloth mask arm, followed by
and conducted an adjusted analysis accordingly. We the control arm, and lowest in the medical mask arm.
fitted a multivariable log-binomial model, using GEE to The same trend was seen for ILI and laboratory tests
account for clustering by ward, to estimate RR after confirmed viral infections. In intention-to-treat analysis,
adjusting for potential confounders. In the initial ILI was significantly higher among HCWs in the cloth
model, we included all the variables that had p value masks group (RR=13.25 and 95% CI 1.74 to 100.97),
less than 0.25 in the univariable analysis, along with the compared with the medical masks group. The rate of
main exposure variable (randomisation arm). A back- ILI was also significantly higher in the cloth masks arm
ward elimination method was used to remove the vari- (RR=3.49 and 95% CI 1.00 to 12.17), compared with the
ables that did not have any confounding effect. control arm. Other outcomes were not statistically signifi-
As most participants in the control arm used a mask cant between the three arms.
during the trial period, we carried out a post-hoc ana- Among the 68 laboratory-confirmed cases, 58 (85%)
lysis comparing all participants who used only a medical were due to rhinoviruses. Other viruses detected were
mask (from the control arm and the medical mask arm) hMPV (7 cases), influenza B (1 case), hMPV/rhinovirus
with all participants who used only a cloth mask (from co-infection (1 case) and influenza B/rhinovirus
the control arm and the cloth arm). For this analysis, co-infection (1 case) (table 3). No influenza A or RSV
controls who used both types of mask (n=245) or used infections were detected.
N95 respirators (n=3) or did not use any masks (n=2) Compliance was significantly higher in the cloth mask
were excluded. We fitted a multivariable log-binomial arm (RR=2.41, 95% CI 2.01 to 2.88) and medical masks

Open Access
Table 1 Demographic and other characteristics by arm of randomisation
Medical mask Cloth mask Control
(% and 95% CI) (% and 95% CI) (% and 95% CI)
Variable (n=580) (n=569) (n=458)
Gender (male) 112/580 133/569 112/458
19.3 (16.2 to 22.8) 23.4 (20.0 to 27.1) 24.5 (20.6 to 28.7)
Age (mean) 36 (35.6 to 37.3) 35 (34.6 to 36.3) 36 (35.1 to 37.0)
Education (postgraduate) 114/580 99/569 78/458
19.7 (16.5 to 23.1) 17.4 (14.3 to 20.8) 17.0 (13.7 to 20.8)
Smoker (current/ex) 78/580 79/569 66/458
13.4 (10.8 to 16.5) 13.9 (11.1 to 17.0) 14.4 (11.3 to 18.0)
Pre-existing illness* 66/580 70/569 47/458
11.4 (9.0 to 14.2) 12.3 (9.8 to 15.3) 10.3 (7.8 to 13.4)
Influenza vaccination (yes) 21/580 21/569 15/458
3.6 (2.4 to 5.4) 3.7 (2.4 to 5.6) 3.3 (2.0 to 5.3)
Staff (doctors) 176/580 165/569 134/458
30.3 (26.6 to 34.3) 29.0 (25.3 to 32.9) 29.3 (25.1 to 33.7)
Number of hand washings per day 14 (13.8 to 15.4) 11 (10.9 to 11.9) 12 (11.5 to 12.7)
(geometric mean)†
Number of patients had contact with 21 (0 to 540) 21 (0 to 661) 18 (3 to 199)
(median and range)‡
*Includes asthma, immunocompromised and others.
†‘Hand wash’ variable was created by taking average of the number of hand washes performed by a healthcare worker (HCW) over the trial
period. The variable was log transformed for the multivariate analysis.
‡‘Number of patients had contact with’ variable was created by taking average of the number of patients in contact with a HCW over the trial
period. Median and range is presented in the table.
arm (RR=2.40, 95% CI 2.00 to 2.87), compared with the either reported using a N95 respirator (n=3) or did not
control arm. Figure 3 shows the percentage of partici- use any masks (n=2).
pants who were compliant in the three arms. A post-hoc Table 5 shows an additional analysis comparing all par-
analysis adjusted for compliance and other potential con- ticipants who used only a medical mask (from the
founders showed that the rate of ILI was significantly control arm and the medical mask arm) with all partici-
higher in the cloth mask arm (RR=13.00, 95% CI 1.69 to pants who used only a cloth mask (from the control arm
100.07), compared with the medical masks arm (table 4). and the cloth arm). In the univariate analysis, all out-
There was no significant difference between the medical comes were significantly higher in the cloth mask group,
mask and control arms. Hand washing was significantly compared with the medical masks group. After adjusting
protective against laboratory-confirmed viral infection for other factors, ILI (RR=6.64, 95% CI 1.45 to 28.65)
(RR=0.66, 95% CI 0.44 to 0.97). and laboratory-confirmed virus (RR=1.72, 95% CI 1.01
In the control arm, 170/458 (37%) used medical to 2.94) remained significantly higher in the cloth masks
masks, 38/458 (8%) used cloth masks, and 245/458 group compared with the medical masks group.
(53%) used a combination of both medical and cloth Table 6 compares the outcomes in the medical mask
masks during the study period. The remaining 1% arm with two previously published trials.8 9 This shows
that while the rates of CRI were significantly higher in
one of the previously published trials, the rates of
laboratory-confirmed viruses were not significantly differ-
ent between the three trials for medical mask use.
On average, HCWs worked for 25 days during the trial
period and washed their cloth masks for 23/25 (92%)
days. The most common approach to washing cloth
masks was self-washing (456/569, 80%), followed by
combined self-washing and hospital laundry (91/569,
16%), and only hospital laundry (22/569, 4%). Adverse
events associated with facemask use were reported in
40.4% (227/562) of HCWs in the medical mask arm
and 42.6% (242/568) in the cloth mask arm ( p value
Figure 2 Outcomes in trial arms (CRI, clinical respiratory 0.450). General discomfort (35.1%, 397/1130) and
illness; ILI, influenza-like illness; Virus, laboratory-confirmed breathing problems (18.3%, 207/1130) were the most
viruses). frequently reported adverse events.

Open Access
Table 2 Intention-to-treat analysis
Laboratory-
confirmed
CRI RR ILI RR viruses RR
N (%) (95% CI) N (%) (95% CI) N (%) (95% CI)
Medical mask* 28/580 (4.83) Ref 1/580 (0.17) Ref 19/580 (3.28) Ref
Cloth masks† 43/569 (7.56) 1.57 (0.99 to 2.48) 13/569 (2.28) 13.25 (1.74 to 100.97) 31/569 (5.45) 1.66 (0.95 to 2.91)
Control‡ 32/458 (6.99) 1.45 (0.88 to 2.37) 3/458 (0.66) 3.80 (0.40 to 36.40) 18/458 (3.94) 1.20 (0.64 to 2.26)
Bold typeface indicates statistically significant.
*p Value from cluster adjusted χ2 tests is 0.510 and intracluster correlation coefficients is 0.065.
†p Value from cluster adjusted χ2 tests is 0.028 and intracluster correlation coefficients is 0.029.
‡p Value from cluster adjusted χ2 tests is 0.561 and intracluster correlation coefficients is 0.068.
CRI, clinical respiratory illness; ILI, influenza-like illness; RR, relative risk.
Laboratory tests showed the penetration of particles HCWs. The virus may survive on the surface of the face-
through the cloth masks to be very high (97%) com- masks,29 and modelling studies have quantified the con-
pared with medical masks (44%) (used in trial) and 3M tamination levels of masks.30 Self-contamination through
9320 N95 (<0.01%), 3M Vflex 9105 N95 (0.1%). repeated use and improper doffing is possible. For
example, a contaminated cloth mask may transfer patho-
gen from the mask to the bare hands of the wearer. We
DISCUSSION also showed that filtration was extremely poor (almost
We have provided the first clinical efficacy data of cloth 0%) for the cloth masks. Observations during SARS sug-
masks, which suggest HCWs should not use cloth masks as gested double-masking and other practices increased the
protection against respiratory infection. Cloth masks risk of infection because of moisture, liquid diffusion
resulted in significantly higher rates of infection than and pathogen retention.31 These effects may be asso-
medical masks, and also performed worse than the control ciated with cloth masks.
arm. The controls were HCWs who observed standard prac- We have previously shown that N95 respirators provide
tice, which involved mask use in the majority, albeit with superior efficacy to medical masks,8 9 but need to be
lower compliance than in the intervention arms. The worn continuously in high-risk settings to protect HCWs.9
control HCWs also used medical masks more often than Although efficacy for medical masks was not shown, effi-
cloth masks. When we analysed all mask-wearers including cacy of a magnitude that was too small to be detected is
controls, the higher risk of cloth masks was seen for possible.8 9 The magnitude of difference between cloth
laboratory-confirmed respiratory viral infection. masks and medical masks in the current study, if
The trend for all outcomes showed the lowest rates of explained by efficacy of medical masks alone, translates
infection in the medical mask group and the highest to an efficacy of 92% against ILI, which is possible, but
rates in the cloth mask arm. The study design does not not consistent with the lack of efficacy in the two previous
allow us to determine whether medical masks had effi- RCTs.8 9 Further, we found no significant difference in
cacy or whether cloth masks were detrimental to HCWs rates of virus isolation in medical mask users between the
by causing an increase in infection risk. Either possibil- three trials, suggesting that the results of this study could
ity, or a combination of both effects, could explain our be interpreted as partly being explained by a detrimental
results. It is also unknown whether the rates of infection effect of cloth masks. This is further supported by the
observed in the cloth mask arm are the same or higher fact that the rate of virus isolation in the no-mask control
than in HCWs who do not wear a mask, as almost all group in the first Chinese RCT was 3.1%, which was not
participants in the control arm used a mask. The phys- significantly different to the rates of virus isolation in the
ical properties of a cloth mask, reuse, the frequency and medical mask arms in any of the three trials including
effectiveness of cleaning, and increased moisture reten- this one. Unlike the previous RCTs, circulating influenza
tion, may potentially increase the infection risk for and RSV were almost completely absent during this study,
Table 3 Type of virus isolated

Influenza hMPV & Influenza
Study arm hMPV Rhino B virus rhino B virus & rhino Total
Medical masks arm 1 16 1 1 0 19
Cloth mask arm 4 26 0 0 1 31
Control arm 2 16 0 0 0 18
Total 7 58 1 1 1 68
hMPV, human metapneumovirus; Rhino, rhinoviruses.

Open Access
wards. Infection control guidelines need to acknowledge
the widespread real-world practice of cloth masks and
should comprehensively address their use. In addition,
other important infection control measure such as hand
hygiene should not be compromised. We confirmed the
protective effects of hand hygiene against laboratory-
confirmed viral infection in this study, but mask type was
an independent predictor of clinical illness, even
adjusted for hand hygiene.
A limitation of this study is that we did not measure
compliance with hand hygiene, and the results reflect
self-reported compliance, which may be subject to recall
Figure 3 Compliance with the mask wearing—mask wearing or other types of bias. Another limitation of this study is
more than 70% of working hours. the lack of a no-mask control group and the high use of
masks in the controls, which makes interpretation of the
with rhinoviruses comprising 85% of isolated pathogens, results more difficult. In addition, the quality of paper
which means the measured efficacy is against a different and cloth masks varies widely around the world, so the
range of circulating respiratory pathogens. Influenza and results may not be generalisable to all settings. The lack
RSV predominantly transmit through droplet and of influenza and RSV (or asymptomatic infections)
contact routes, while Rhinovirus transmits through mul- during the study is also a limitation, although the pre-
tiple routes, including airborne and droplet routes.32 33 dominance of rhinovirus is informative about pathogens
The data also show that the clinical case definition of ILI transmitted by the droplet and airborne routes in this
is non-specific, and captures a range of pathogens other setting. As in previous studies, exposure to infection
than influenza. The study suggests medical masks may be outside the workplace could not be estimated, but we
protective, but the magnitude of difference raises the pos- would assume it to be equally distributed between trial
sibility that cloth masks cause an increase in infection risk arms. The major strength of the randomised trial study
in HCWs. Further, the filtration of the medical mask used design is in ensuring equal distribution of confounders
in this trial was poor, making extremely high efficacy of and effect modifiers (such as exposure outside the work-
medical masks unlikely, particularly given the predomin- place) between trial arms.
ant pathogen was rhinovirus, which spreads by the air- Cloth masks are used in resource-poor settings because
borne route. Given the obligations to HCW occupational of the reduced cost of a reusable option. Various types of
health and safety, it is important to consider the potential cloth masks (made of cotton, gauze and other fibres)
risk of using cloth masks. have been tested in vitro in the past and show lower filtra-
In many parts of the world, cloth masks and medical tion capacity compared with disposable masks.7 The pro-
masks may be the only options available for HCWs. tection afforded by gauze masks increases with the
Cloth masks have been used in West Africa during the fineness of the cloth and the number of layers,37 indicat-
Ebola outbreak in 2014, due to shortages of PPE, ( per- ing potential to develop a more effective cloth mask, for
sonal communication, M Jalloh). The use of cloth masks example, with finer weave, more layers and a better fit.
is recommended by some health organisations, with Cloth masks are generally retained long term and
caveats.34–36 In light of our study, and the obligation to reused multiple times, with a variety of cleaning
ensure occupational health and safety of HCWs, cloth methods and widely different intervals of cleaning.34
masks should not be recommended for HCWs, particu- Further studies are required to determine if variations in
larly during AGPs and in high-risk settings such as emer- frequency and type of cleaning affect the efficacy of
gency, infectious/respiratory disease and intensive care cloth masks.
Table 4 Multivariable cluster-adjusted log-binomial model to calculate RR for study outcomes

CRI ILI Laboratory-confirmed viruses
RR (95% CI) RR (95% CI) RR (95% CI)
Medical masks arm Ref Ref Ref
Cloth mask arm 1.56 (0.97 to 2.48) 13.00 (1.69 to 100.07) 1.54 (0.88 to 2.70)
Control arm 1.51 (0.90 to 2.52) 4.64 (0.47 to 45.97) 1.09 (0.57 to 2.09)
Male 0.67 (0.41 to 1.12) 1.03 (0.34 to 3.13) 0.65 (0.34 to 1.22)
Vaccination 0.83 (0.27 to 2.52) 1.74 (0.24 to 12.56) 1.27 (0.41 to 3.92)
Hand washing 0.91 (0.66 to 1.26) 0.94 (0.40 to 2.20) 0.66 (0.44 to 0.97)
Compliance 1.14 (0.77 to 1.69) 1.86 (0.67 to 5.21) 0.86 (0.53 to 1.40)
CRI, clinical respiratory illness; ILI, influenza-like illness; RR, relative risk.

Open Access
Table 5 Univariate and adjusted analysis comparing participants who used medical masks and cloth masks*
Univariate Adjusted
RR (95% CI) RR (95% CI)
CRI
Medical mask (35/750, 4.67%) Ref Ref
Cloth mask (46/607, 7.58%) 1.62 (1.06 to 2.49) 1.51 (0.97 to 2.32)
Male 0.60 (0.32 to 1.12) 0.58 (0.31 to 1.08)
Vaccination 0.66 (0.17 to 2.62) 0.68 (0.17 to 2.67)
Hand washing 0.81 (0.58 to 1.15) 0.84 (0.59 to 1.20)
Compliance 1.01 (1.00 to 1.03) 1.01 (1.00 to 1.02)
ILI
Cloth mask (13/607, 2.14%) 8.03 (1.82 to 35.45) 6.64 (1.45 to 28.65)
Male 0.95 (0.27 to 3.35) 0.92 (0.26 to 3.22)
Compliance 1.04 (1.01 to 1.08) 1.04 (1.00 to 1.08)
Laboratory-confirmed viruses
Cloth mask (34/607, 5.60%) 1.91 (1.13 to 3.23) 1.72 (1.01 to 2.94)
Male 0.64 (0.30 to 1.33) 0.61 (0.29 to 1.27)
Compliance 1.00 (0.99 to 1.02) 1.0 (0.99 to 1.02)
*The majority (456/458) of HCWs in the control arm used a mask. Controls who exclusively used a medical mask were categorised and
analysed with the medical mask arm participants; and controls who exclusively wore a cloth mask were categorised and analysed with the
cloth mask arm.
CRI, clinical respiratory illness; HCWs, healthcare workers; ILI, influenza-like illness; RR, relative risk.
Table 6 A comparison of outcome data for the medical mask arm with medical mask outcomes in previously published RCTs
Laboratory-
confirmed
CRI RR ILI RR viruses RR
N (%) (95% CI) N (%) (95% CI) N (%) (95% CI)
Vietnam trial 28/580 (4.83) Ref 1/580 (0.17) Ref 19/580 (3.28) Ref
Published RCT 33/492 (6.70) 1.40 (0.85 to 2.26) 3/492 (0.61) 3.53 (0.37 to 33.89) 13/492 (2.64) 0.80 (0.40 to 1.62)
China 18
Published RCT 98/572 (17.13) 3.54 (2.37 to 5.31) 4/572 (0.70) 4.06 (0.45 to 36.18) 19/572 (3.32) 1.01 (0.54 to 1.89)
China 29
CRI, Clinical respiratory illness; ILI, influenza-like illness; RCT, randomised clinical trial; RR, relative risk.
Pandemics and emerging infections are more likely to out, cloth masks should not be recommended. We also
arise in low-income or middle-income settings than in recommend that infection control guidelines be
wealthy countries. In the interests of global public updated about cloth mask use to protect the occupa-
health, adequate attention should be paid to cloth mask tional health and safety of HCWs.
use in such settings. The data from this study provide
some reassurance about medical masks, and are the first Author affiliations
1
data to show potential clinical efficacy of medical masks. Faculty of Medicine, School of Public Health and Community Medicine,
Medical masks are used to provide protection against University of New South Wales, Sydney, Australia
2
National Institute of Hygiene and Epidemiology, Hanoi, Vietnam
droplet spread, splash and spray of blood and body 3
Institute for Clinical Pathology and Medical Research, Westmead Hospital
fluids. Medical masks or respirators are recommended and University of Sydney, Sydney, New South Wales, Australia
4
by different organisations to prevent transmission of Beijing Centers for Disease Control and Prevention, Beijing, China
Ebola virus, yet shortages of PPE may result in HCWs
Acknowledgements The authors would like to thank the staff members from
being forced to use cloth masks.38–40 In the interest of
the National Institute of Hygiene and Epidemiology, Hanoi, Vietnam, who were
providing safe, low-cost options in low income countries, involved with the trial. They thank as well to the staff from the Hanoi hospitals
there is scope for research into more effectively who participated. They also acknowledge the support of 3M for testing of
designed cloth masks, but until such research is carried filtration of the facemasks. 3M was industry partner in the ARC linkage project

Open Access
grant; however they were not involved in study design, data collection or 9. MacIntyre CR, Wang Q, Seale H, et al. A randomised clinical trial of
analysis. The 3M products were not used in this study. three options for N95 respirators and medical masks in health
workers. Am J Respir Crit Care Med 2013;187:960–6.
Contributors CRM was the lead investigator, and responsible for the 10. Chughtai AA, MacIntyre CR, Zheng Y, et al. Examining the policies
conception and design of the trial, obtaining the grant funding, overseeing and guidelines around the use of masks and respirators by
the whole study, analysing the data and writing of the report. HS healthcare workers in China, Pakistan and Vietnam. J Infect Prev
contributed to overseeing the study, staff training, form/database 2015;16:68–74.
11. Chughtai AA, Seale H, Chi Dung T, et al. Current practices and
development and drafting of the manuscript. TCD was responsible for
barriers to the use of facemasks and respirators among
overseeing the study, database management, recruitment, training and hospital-based health care workers in Vietnam. Am J Infect Control
revision of the manuscript. NTH was responsible for the implementation 2015;43:72–7.
of research and revision of the manuscript. PTN was responsible for the 12. Pang X, Zhu Z, Xu F, et al. Evaluation of control measures
laboratory testing in Vietnam. AAC contributed to the statistical analysis and implemented in the severe acute respiratory syndrome outbreak in
drafting of the manuscript. BR was responsible for the statistical analysis Beijing. JAMA 2003;290:3215–21.
13. Yang P, Seale H, MacIntyre C, et al. Mask-wearing and respiratory
and revision of the manuscript. DED contributed to the laboratory technical
infection in healthcare workers in Beijing, China. Braz J Infect Dis
assistance and revision of the manuscript. QW assisted in comparing the 2011;15:102–8.
rates of infection from two previous RCTs conducted in China and revision 14. Horton R. Medical journals: evidence of bias against the diseases of
of the manuscript. poverty. Lancet 2003;361:712–13.
15. MacIntyre CR, Chughtai AA. Facemasks for the prevention of
Funding Funding to conduct this study was received from the Australian infection in healthcare and community settings. BMJ 2015;350:h694.
Research Council (ARC) (grant number LP0990749). 16. Chughtai AA, Seale H, MacIntyre CR. Availability, consistency and
evidence-base of policies and guidelines on the use of mask and
Competing interests CRM has held an Australian Research Council Linkage respirator to protect hospital health care workers: a global analysis.
Grant with 3M as the industry partner, for investigator-driven research. 3M BMC Res Notes 2013;6:1–9.
has also contributed masks and respirators for investigator-driven clinical 17. MacIntyre C, Cauchemez S, Dwyer D, et al. Face mask use and
trials. CRM has received research grants and laboratory testing as in-kind control of respiratory virus transmission in households. Emerg Infect
Dis 2009;15:233–41.
support from Pfizer, GSK and Bio-CSL for investigator-driven research. HS
18. Buecher C, Mardy S, Wang W, et al. Use of a multiplex PCR/RT-
had a NHMRC Australian-based Public Health Training Fellowship at the time PCR approach to assess the viral causes of influenza-like illnesses
of the study (1012631). She has also received funding from vaccine in Cambodia during three consecutive dry seasons. J Med Virol
manufacturers GSK, bio-CSL and Sanofi Pasteur for investigator-driven 2010;82:1762-72 [Epub ahead of print 1 Sep 2010].
research and presentations. AAC used filtration testing of masks for his PhD 19. Higuchi R, Fockler C, Dollinger G, et al. Kinetic PCR analysis: real-
thesis conducted by 3M Australia. time monitoring of DNA amplification reactions. Biotechnology (N Y)
1993;11:1026–30 [Epub ahead of print 1 Sep 2010].
Ethics approval National Institute for Hygiene and Epidemiology (NIHE) (approval 20. Hummel KB, Lowe L, Bellini WJ, et al. Development of quantitative
number 05 IRB) and the Human Research Ethics Committee of the University of gene-specific real-time RT-PCR assays for the detection of measles
virus in clinical specimens. J Virol Methods 2006;132:166–73 [Epub
New South Wales (UNSW), Australia, (HREC approval number 10306).
ahead of print 11 Sep 2005].
Provenance and peer review Not commissioned; externally peer reviewed. 21. Mackay IM. Real-time PCR in microbiology. Caister Academic
Press, 2007.
Data sharing statement No additional data are available. 22. Wang W, Cavailler P, Ren P, et al. Molecular monitoring of causative
viruses in child acute respiratory infection in endemo-epidemic
Open Access This is an Open Access article distributed in accordance with situations in Shanghai. J Clin Virol (PASCV) 2010;49:211–8.
the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, 23. Thi TN, Deback C, Malet I, et al. Rapid determination of antiviral
which permits others to distribute, remix, adapt, build upon this work non- drug susceptibility of herpes simplex virus types 1 and 2 by real-time
commercially, and license their derivative works on different terms, provided PCR. Antiviral Res 2006;69:152–7.
24. Standards Australia Limited/Standards New Zealand. Respiratory
the original work is properly cited and the use is non-commercial. See: http://
protective devices. Australian/New Zealand Standard. AS/NZS 1716:
creativecommons.org/licenses/by-nc/4.0/ 2012.
25. Donner A, Klar N. Design and analysis of cluster randomization trials
in health research. London: Oxford University Press Inc, 2000.
26. Campbell MK, Elbourne DR, Altman DG, et al. CONSORT
REFERENCES statement: extension to cluster randomised trials. BMJ
1. World Health Organization (WHO). Global Alert and Response 2004;328:702–8.
(GAR), Pandemic (H1N1) 2009—update 76 (cited 27 Apr 2012). 27. Vittinghoff E, Glidden DV, Shiboski SC, et al. Regression methods in
http://www.who.int/csr/don/2009_11_27a/en/index.html biostatistics. 2nd edn. New York: Springer-Verlag, 2012.
2. World Health Organization (WHO). Human infection with avian 28. StataCorp. Stata 12 base reference manual. College Station, TX:
influenza A(H7N9) virus—update (cited 8 May 2013). http://www. Stata Press, 2011.
who.int/csr/don/2013_05_07/en/index.html 29. Osterholm MT, Moore KA, Kelley NS, et al. Transmission of Ebola
3. Bermingham A, Chand MA, Brown CS, et al. Severe respiratory viruses: what we know and what we do not know. mBio 2015;6:
illness caused by a novel coronavirus, in a patient transferred to the e00137–15.
United Kingdom from the Middle East, September 2012. Euro 30. Fisher EM, Noti JD, Lindsley WG, et al. Validation and application of
Surveill 2012;17:20290. models to predict facemask influenza contamination in healthcare
4. Pollack MP, Pringle C, Madoff LC, et al. Latest outbreak news from settings. Risk Anal 2014;34:1423–34.
ProMED-mail: novel coronavirus—Middle East. Int J Infect Dis 31. Li Y, Wong T, Chung J, et al. In vivo protective performance of N95
2013;17:e143–4. respirator and surgical facemask. Am J Ind Med 2006;49:1056–65.
5. World Health Organization (WHO). Global Alert and Response 32. Dick EC, Jennings LC, Mink KA, et al. Aerosol transmission of
(GAR). Ebola virus disease update—west Africa 2014 (cited 28 Aug rhinovirus colds. J Infect Dis 1987;156:442–8.
2014). http://www.who.int/csr/don/2014_08_28_ebola/en/ 33. Bischoff WE. Transmission route of rhinovirus type 39 in a
6. Chughtai AA, Seale H, MacIntyre CR. Use of cloth masks in the monodispersed airborne aerosol. Infect Control Hosp Epidemiol
practice of infection control—evidence and policy gaps. Int J Infect 2010;31:857–9.
Control 2013;9:1–12. 34. Institute of Medicine (IOM). Reusability of Facemasks During an
7. Quesnel LB. The efficiency of surgical masks of varying design and Influenza Pandemic: Facing the Flu—Committee on the
composition. Br J Surg 1975;62:936–40. Development of Reusable Facemasks for Use During an Influenza
8. MacIntyre CR, Wang Q, Cauchemez S, et al. A cluster Pandemic. National Academy of Sciences, 2006.
randomized clinical trial comparing fit-tested and non-fit-tested 35. Center for Disease Control and Prevention and World Health
N95 respirators to medical masks to prevent respiratory virus Organization. Infection control for viral haemorrhagic fevers in the
infection in health care workers. Influenza Other Respir Viruses African health care setting. Atlanta: Centers for Disease Control and
2011;5:170–9. Prevention, 1998:1–198.

Open Access
36. World Health Organization (WHO). Guidelines for the prevention of 39. Center for Disease Control and Prevention (CDC). Guidance on
tuberculosis in health care facilities in resource limited settings, Personal Protective Equipment To Be Used by Healthcare Workers
1999. During Management of Patients with Ebola Virus Disease in U.S.
37. Weaver GH. Droplet infection and its prevention by the face mask. Hospitals, Including Procedures for Putting On (Donning) and
J Infect Dis 1919;24:218–30. Removing (Doffing). 2014 (cited 23 Oct 2014). http://www.cdc.gov/
38. MacIntyre CR, Chughtai AA, Seale H, et al. Respiratory vhf/ebola/hcp/procedures-for-ppe.html
protection for healthcare workers treating Ebola virus disease 40. World Health Organiszation (WHO). Infection prevention and control
(EVD): are facemasks sufficient to meet occupational guidance for care of patients in health-care settings, with focus on
health and safety obligations? Int J Nurs Stud 2014;51: Ebola. 2014 (cited 23 Oct 2014). http://www.who.int/csr/resources/
1421–6. publications/ebola/filovirus_infection_control/en/

,,-
CABINET FOR HEALTH AND FAMILY SERVICES

OFFICE OF LEGAL SERVICES
Andy Beshear 275 East Main Street, 5W-B Eric C. Friedlander

Governor Frankfort, KY 40621 Acting Secretary
502-564-7905
502-564-7573 Wesley W. Duke
www.chfs.ky.gov
General Counsel
ORDER
March 19, 2020
On March 6, 2020, Governor Andy Beshear signed Executive Order 2020-215, declaring a state of
emergency in the Commonwealth due to the outbreak of COVID-19 virus, a public health emergency.
Pursuant to the authority in KRS 194A.025, KRS 214.020, KRS Chapter 39A, and Executive Orders
2020-215 and 2020-243, the Cabinet for Health and Family Services, Department of Public Health,
hereby orders the following directives to reduce and slow the spread of COVID-19:
1. All mass gatherings are hereby prohibited.
2. Mass gatherings include any event or convening that brings together groups of
individuals, including, but not limited to, community, civic, public, leisure,
faith-based, or sporting events; parades; concerts; festivals; conventions;
fundraisers; and similar activities.
3. For the avoidance of doubt, a mass gathering does not include normal
operations at airports, bus and train stations, medical facilities, libraries,
shopping malls and centers, or other spaces where persons may be in transit. It
also does not include typical office environments, factories, or retail or
grocery stores where large numbers of people are present, but maintain
appropriate social distancing.
4. Any gathering, regardless of whether it is a mass gathering prohibited under

this Order, shall to the extent practicable implement Centers for Disease
Control guidance, including:
• maintaining a distance of 6 feet between persons;
KentuckyUnbridledSpirit.com An Equal Opportunity Employer M/F/D

• encouraging good hygiene measures, including regular, thorough

handwashing, and providing adequate hygiene materials, including hand
sanitizing options;
• encouraging people who are sick to remain home or leave the premises;
and
• regularly cleaning and disinfecting frequently touched objects and

surfaces.
5. The Department of Public Health hereby delegates to local health departments

the authority to take all necessary measures to implement this Order.
The Cabinet for Health and Family Services will monitor these directives continuously. The Cabinet
will c ·nue to provide information and updates to healthcare providers during the duration of this
Publi H alth Emerg ncy.
Commi
Depart
Cabin
Eric Friedlander
�ecretary
Governor's Designee
VERSION 1.1 – Effective May 9, 2020
Guidelines for Places of Worship

Places of worship will be expected to meet the Healthy at Work Minimum
Requirements. In addition, places of worship should follow the guidelines in order
to reopen and remain open:
Social Distancing
• Places of worship should, to the greatest extent practicable, continue to conduct
alternative services, including tele-services, radio broadcasts, and drive-in services.
• Places of worship conducting drive-in services should ensure their congregants remain in
their vehicles and not socialize through their vehicle windows, except at a distance of
more than six (6) feet. Attendees should turn off their vehicles to avoid idling and protect
everyone’s health.
• Places of worship conducting in-person services should limit attendance to no more than
33% of the building occupancy capacity, including clergy and staff-employees, while
maintaining social distance between household units of at least six (6) feet. This means
that there must be six (6) feet between individuals on a row and individuals between
rows, such that a six-foot radius is maintained around all household units. A place of
worship that cannot maintain this space must further reduce its occupancy capacity until
it is achieved.
• Places of worship should ensure, to the greatest extent practicable, that clergy, staff-
employees, volunteers and congregants wear coverings (e.g., cloth mask or bandana)
over their mouths and noses while attending services.
• Places of worship should wait to reopen youth services (including, but not limited to,
Sunday schools) until childcare services have reopened on June 15, 2020. Once they
reopen, youth services should follow the requirements posted for childcare services.
• Singing during services creates a higher risk of spreading infectious particles. Choirs
should avoid singing. Congregants should wear face coverings and consider a greater than
six feet social distance from others if they choose to sing. Houses of worship should
consider alternatives to congregational singing, including by playing pre-recorded or live
instrumental music (e.g. pianos and guitars - no wind instruments) during services.
• Places of worship should consider taking congregants’ temperatures and asking about
signs of illness before admitting them into the place of worship. If they do take
temperatures, they should consider using a non-contact thermometer or thermal imager.
If a place of worship must use a standard oral/aural thermometer, consider having the
congregant take their own temperature and relay the information to maintain social
distancing and sanitize the thermometer after each use.
• Places of worship should not allow individuals with elevated temperatures (100.5 degrees
Fahrenheit or above) or signs of illness (coughing, shortness of breath, sneezing) to attend
in-person services. Houses of worship should direct those having symptoms of COVID-19,
as well as people who have had close contact with a person who has symptoms like dry
cough, chest tightness, and/or fever, to refrain from participating in any aspect of in-
person services. Places of worship should encourage symptomatic persons to stay at
home, seek immediate medical care, or get tested.
• Places of worship should use greeters to direct congregants to available masks and
bulletins. Greeters should be masked, maintain social distancing, and consider wearing
gloves.
• Places of worship should display markers and signage in the sanctuary/meeting space to
guide social distancing.
• Places of worship should communicate with the congregation often and with clarity and
transparency. Prepare the congregation for worship and for the changes that are
occurring in procedures due to the national health crisis.
• Places of worship making restrooms available must ensure restrooms are only used by
one person at a time and all portions that are regularly touched (e.g., door, sink, and toilet
handles) are appropriately disinfected after each use.
• Places of worship conducting in-person services must, to the greatest extent practicable,
provide hand sanitizer, handwashing facilities, tissues, and waste baskets in convenient
locations.
• Places of worship should not provide communal food or beverages to clergy, staff-
employees, volunteers, or congregants.
• Places of worship should restrict access to common areas, to the greatest extent
practicable, in order to maximize social distancing and reduce congregating. These
common areas include, but are not limited to, foyers, lobbies, vending areas, community
and multi-purpose rooms, and event spaces.
• Because of the requirement to socially distance at least six (6) feet apart, places of
worship should refrain from the practice of handshaking, handholding, or hugging.
• Places of worship should encourage those at higher risk for severe illness per CDC
guidelines not to attend in-person services. These guidelines are available
at:https://www.cdc.gov/coronavirus/2019-ncov/faq.html#Higher-Risk. Instead, places of
worship should, to the greatest extent practicable, provide services that are not in-
person, including tele-services, drive-in services, and/or radio services for those
individuals. If a house of worship is unable to provide alternative services, they should,
to the greatest extent practicable, implement hours where service can be safely provided
to congregants at higher risk for severe illness.
Personal Protective Equipment Requirements

employees, volunteers and congregants wear face coverings (e.g., cloth mask or bandana)
Cleaning and Disinfecting Requirements

• Places of worship must ensure facilities are properly cleaned and ventilated.
• Places of worship must ensure cleaning and sanitation of frequently touched surfaces
with appropriate disinfectants. Appropriate disinfectants include EPA registered
household disinfectants, diluted household bleach solution, and alcohol solutions
containing at least 60% alcohol. Places of worship must establish a cleaning and
disinfecting process that follows CDC guidelines when any individual is identified,
suspected, or confirmed as COVID-19 positive.
• Places of worship, as appropriate, must ensure they do not use cleaning procedures that
could re-aerosolize infectious particles. This includes, but is not limited to, avoiding
practices such as dry sweeping or use of high-pressure streams of air, water, or cleaning
chemicals.
Training and Safety Requirements

• Places of worship should ensure appropriate signage is posted throughout their facilities
to inform clergy, staff-employees, and congregants about good hygiene and new
practices.
• Places of worship should ensure clergy, staff-employees, volunteers, and congregants are
instructed to avoid touching their faces, including their eyes, noses, and mouths,
particularly until after they have thoroughly washed their hands upon completing work
and/or removing PPE, to the greatest extent practicable.
informed that they may identify and communicate potential improvements and/or
concerns in order to reduce potential risk of exposure.

Requirements for Restaurants
In addition to the Healthy at Work Minimum Requirements, restaurants1
must meet the requirements below in order to reopen and remain open:
Social Distancing Requirements
• Restaurants that have provided food and beverage service via curbside, takeout, and
delivery services should continue to do so, to the greatest extent practicable, in order
to minimize the number of persons in the restaurant and contacts between them.
• Restaurants should provide services and conduct business via phone or Internet to the
greatest extent practicable. Any restaurant employees who are currently able to
perform their job duties via telework (e.g., accounting staff) should continue to
telework.
• Restaurants should limit party size to ten (10) people or fewer. Persons not living within
the same household should not be permitted to sit at the same table.
• Restaurants must limit the number of customers present in any given restaurant to 33%
of the maximum permitted occupancy of seating capacity, assuming all individuals in
the restaurant are able to maintain six (6) feet of space between each other with that
level of occupancy. This means no person can be within six (6) feet of a person seated
at another table or booth. If the restaurant is not able to maintain six (6) feet of space
between tables at 33% of capacity, the restaurant must limit the number of individuals
in the restaurant to the greatest number that permits proper social distancing.
Restaurants should consider installation of portable or permanent non-porous physical
barriers (e.g., plexiglass shields) between tables.
• Restaurants should maximize use of outdoor seating. Restaurants must be able to

arrange seating so as to maintain six (6) feet of space between seated customers. This
means no person can be within six (6) feet of a person seated at another table.
• Restaurants should ensure social distancing by limiting customer movement through

the restaurant to the greatest extent practicable. Restaurants should inform customers
that they may travel to entries, exits, and the restroom, unless circumstances (e.g.
healthy and safety) require otherwise. Restaurants should to the greatest extent
practicable, modify the office’s traffic flow to minimize contacts.
1
For purposes of these requirements, a “restaurant” is an entity that stores, prepares, serves, vends food directly
to the consumer or otherwise provides food for human consumption, and must hold a food service permit in good
standing and has table seating.
• If a restaurant has more customers wishing to enter their business than is possible
under the current social distancing requirements of six (6) feet between all individuals,
the restaurant should establish a system for limiting entry and tracking occupancy
numbers. Once a restaurant has reached its capacity, it should permit a new customer
inside only after a previous customer has left the premises on a one-to-one basis.
Restaurants experiencing lines or waits outside their doors should establish a safe
means for customers to await entry, such as asking customers to remain in their car and
notifying them via phone when they are able to enter the restaurant or demarking
spots six (6) feet apart where customers can safely stand without congregating.
• Restaurants should close children’s play areas.
• Restaurants should update floor plans for common dining areas, redesigning seating
arrangement to maximize the ability to social distance to the greatest extent
practicable.
• Restaurants should consider a reservations-only business model or call-ahead seating

to better space households and individuals.
• Restaurants should ensure employees wear face masks for any interactions with
customers, co-workers, or while in common travel areas of the business (e.g., aisles,
hallways, loading docks, breakrooms, bathrooms, entries and exits). Restaurant
employees are not required to wear face masks while alone in personal offices, while
more than six (6) feet from any other individual, or if doing so would pose a serious
threat to their health or safety.
• Restaurants should use disposable menus, napkins, table cloths, disposable utensils,
and condiments to the greatest extent practicable. Restaurants are encouraged to use
electronic menus.
• Restaurants should discontinue use of tablecloths and cloth napkins.
• Restaurants should discontinue use of any self-service drink stations to the greatest
extent practicable. Restaurants continuing self-service drink stations should remove
any unwrapped or non-disposable items (e.g. straws or utensils), as well as fruit (e.g.
lemons), sweeteners, creamers, and any condiment containers that are not in single-
use, disposable packages.
• Restaurants should discontinue use of salad bars and other buffet style dining to the
greatest extent practicable. If a restaurant cannot discontinue buffet style dining, the
restaurant must ensure that employees provide buffet service. Restaurants should not
permit customer self-service. Restaurants providing buffet service should ensure
appropriate sneeze guards are in-place and that employees are equipped with gloves
and other PPE as appropriate.
• Restaurants should ensure employees use digital files rather than paper formats (e.g.,
documentation, invoices, inspections, forms, agendas) to the greatest extent
practicable.
• Restaurants should, to the greatest extent practicable, modify internal traffic flow to
minimize contacts between employees and customers.
• Restaurants should, to the greatest extent practicable, demarcate six feet of distance
between customers and employees except at the moment of payment and/or
exchange of food and drink.
• Restaurants should implement contactless payment options, pickup, and delivery to the
greatest extent practicable.
• Restaurants should ensure, to the greatest extent practicable, that any receipts can be
completed electronically by using e-signature technology for signatures or by creating
a procedure whereby restaurant employees can complete the receipt for the customer
within the customer’s view.
• Restaurants should reduce, to the greatest extent practicable, the number of

employees and customers entering, exiting, or gathering at one time. One suggested
method to accomplish this is by staggering the beginning and end times of employee
shifts. In addition, for customers, one possible method to limit gathering is to allow
only one individual or household unit to enter the restaurant at a time.
• Restaurants that require employees to operate equipment or vehicles must, to the

greatest extent practicable, limit the number of employees riding in the vehicle
together. If riding in separate vehicles is not practicable then employees should
maximize social distancing and wear face masks in the vehicle. Thorough cleaning and
disinfecting vehicles after each trip is required.
• Restaurants must restrict access to common areas, to the greatest extent practicable,
in order to maximize social distancing and reduce congregating. These common areas
include, but are not limited to, break rooms, waiting areas, and bars.
• Restaurants with warehouses and loading docks must ensure minimal interaction
between drivers at loading docks, doorsteps, or other locations.
• Restaurants should, to the greatest extent practicable, limit the number of individuals
in a restroom to ensure proper social distancing and ensure that frequently touched
surfaces are appropriately disinfected (e.g., door knobs and handles).
• Restaurants should provide hand sanitizer, handwashing facilities, and tissues in

convenient locations to the greatest extent practicable.
• Restaurants should prohibit gatherings or meetings of employees of ten (10) or more

during work hours.
• Restaurants should discourage employees from sharing workstations or other work-

related items and utensils, to the greatest extent practicable (e.g., ink pens and
aprons).
• Restaurants should, to the greatest extent practicable, install floor decals in cashier
and queuing areas to establish safe waiting distance.
• Restaurants should remind third-party delivery drivers and any suppliers of the social
distancing requirements.
• Restaurants providing “grab and go” service should stock coolers to no more than
minimum levels to prevent excess touching of items.

• Restaurants should ensure workstations and seating areas are properly cleaned and
ventilated.
• Restaurants should encourage employees to frequently wash their hands or use hand
sanitizer, which should be provided by the restaurant.
• Restaurants must ensure cleaning and sanitation of frequently touched surfaces with
appropriate disinfectants. Areas with frequently touched surfaces or items, include all
seating, table-tops, and other table-top items, door handles, phones, pens, and
keypads. Appropriate disinfectants include EPA registered household disinfectants,
diluted household bleach solution, and alcohol solutions containing at least 60%
alcohol. Restaurants must establish a cleaning and disinfecting process that follows
CDC guidelines when any individual is identified, suspected, or confirmed COVID-19
case.
• Restaurants should ensure employees wipe their workstations/cash registers down

with disinfectant at the end of their shift or at any time they discontinue use of their
workstations/cash register for a significant period of time.
• Restaurants should ensure disinfecting wipes or other disinfectant are available near
shared equipment (e.g. in kitchen, wait stations, and hostess stations).
• Restaurants should encourage customers to use hand sanitizer or wipes prior to dining
in the restaurant and immediately following their meal.
• Restaurants should ensure employees do not use cleaning procedures that could re-
aerosolize infectious particles. This includes, but is not limited to, avoiding practices
such as dry sweeping or use of high-pressure streams of air, water, or cleaning
chemicals.
Personal Protective Equipment (PPE) Requirements
• Restaurants must ensure appropriate face coverings and other personal protective
equipment (PPE) is used by employees whenever they are near other employees or
customers so long as such use does not jeopardize the employees’ health or safety.
Restaurants shall provide PPE at no cost to employees and should offer instruction on
proper use of masks and PPE.
• Restaurants must require contractors, vendors, and drivers to wear face coverings or
masks while at the location.
• Restaurants should establish a policy as to whether to serve customers who do not

adhere to the business’s policy on requiring masks while in common areas. While
customers of course will have to remove their masks in order to eat and drink, restaurants
may choose not to serve those customers who refuse to wear a mask while away from
their booth/table (i.e. entering, exiting, going to the restroom) in order to protect their
employees and other customers.
• Restaurants must train employees to properly dispose of or disinfect PPE, inspect PPE
for damage, maintain PPE, and the limitations of PPE.
• Restaurants must ensure, to the greatest extent practicable, that employees use gloves,
along with any PPE normally used for routine job tasks, when cleaning equipment,
workspaces, and high-touch areas of the business.
• Restaurants must ensure gloves are available to employees engaging in high-touch

activity to the greatest extent practicable provided that they do not create additional
hazards while being worn.
• Restaurants must ensure, to the greatest extent practicable, that employees wear
gloves while handling products delivery.
• Restaurants must ensure, to the greatest extent practicable, that employees wear
protective face coverings and gloves during any delivery.

• Restaurants must place conspicuous signage at entrances and throughout the
restaurant alerting staff and customers to the required occupancy limits, six feet of
physical distance, and policy on face coverings. Signage should inform employees and
customers about good hygiene and new practices.
• Restaurants should establish procedures for disinfecting table tops, seating, and dining
ware (plates, bowls, utensils).
• Restaurants should post signage on entrance door that no one with a fever or
symptoms of COVID-19 is to be permitted in the restaurant.
• Restaurants should, to the greatest extent practicable, implement hours where service
can be safely provided to customers at higher risk for severe illness per CDC guidelines.
These guidelines are available at: https://www.cdc.gov/coronavirus/2019-
ncov/faq.html#Higher-Risk
• Restaurants should ensure employees are informed that they may identify and
communicate potential improvements and/or concerns in order to reduce potential
risk of exposure at the workplace. All education and training must be communicated in
the language best understood by the individual receiving the education and training.
Requirements for Construction Businesses

In addition to the Healthy at Work Minimum Requirements, construction
businesses must meet the requirements below in order to reopen and remain
open:
• Businesses must ensure that employees adhere to social distancing guidelines by staying
at least six (6) feet away from other people whenever possible. Controls must be
established and maintained when six (6) feet of physical distancing is not feasible.
• Businesses are encouraged to create phased plans for employees to return to on-site
work and use site and project organizational planning to restrict on-site personnel to
those required for that day’s activities. Work crews should be separated wherever
possible. Employers must limit face-to-face meetings. Employers should use
teleconferencing, video conferencing, and other methods that do not require face-to-face
interaction.
• Businesses must, to the greatest extent practicable, restrict access to common areas such
as lobbies, waiting rooms, break rooms, and concession areas. No communal coolers or
drink stations are allowed. For common areas that cannot be closed, social distancing
signage and markers should be used to discourage congregation. Businesses must
sanitize any common area immediately after each use.
• Businesses must, to the greatest extent practicable, limit the number of people riding in
a vehicle together. If riding in separate vehicles is not practicable, employees should
maximize social distancing and wear face masks in the vehicle. Thorough cleaning and
disinfecting vehicles after each trip is required.

• Businesses must ensure that adequate supplies of soap and/or sanitizer are readily
available to employees and that they promote frequent hand washing by setting up
multiple, easily accessible sanitation locations.
• Businesses must ensure cleaning and sanitation of frequently touched equipment, tools,
objects, and surfaces with appropriate disinfectants. This may include, but is not limited
to: vehicle/equipment door handles; keys; gear shifts; steering wheel/operator controls
and levers; fuel pump dispensers; door knobs; light switches; phones;
computers/keyboards; copiers; elevator buttons; toilets; faucets; sinks; countertops;
paper towel dispensers; desktops; handrails; folders; vending machines; counters; tables;
and cabinets and knobs. Appropriate disinfectants include EPA registered household
disinfectants, diluted household bleach solution, and alcohol solutions containing at least
60% alcohol.
• Businesses must ensure, to greatest extent practicable, that facilities and work areas are
sanitized and disinfected after persons suspected or confirmed to have COVID-19 have
been in the facility or work area.
• Businesses must, to the greatest extent practicable, close off areas used by the ill persons
and wait as long as practical before beginning cleaning and disinfection to minimize
potential for exposure to respiratory droplets. Open outside doors and windows to
increase ventilation and wait up to 24 hours before beginning cleaning and disinfection if
possible.
• Businesses must, to the greatest extent practicable, discourage employees from sharing
tools or equipment. Shared tools and equipment must be disinfected between uses.

• Businesses must ensure employees use appropriate face coverings and other personal
protective equipment (PPE). No sharing of PPE is permissible. Businesses should ensure
employees wear appropriate face coverings at all times practicable. For employees that
are isolated in closed offices, assigned areas with more than six (6) feet of social distancing
or remote areas, face coverings are not necessary at all times. However, when an
employee may come within six feet of other people, a face covering must be worn. If not
required by OSHA for a job task, N95 / KN95 masks shall not be provided to non-
healthcare sector workers as face coverings. Cloth masks shall be used instead.

• Businesses must appoint a Safety Coordinator to manage Healthy at Work requirements
at each construction job or work site and coordinate with the business’s Healthy at
Work Officer.
• Businesses must provide special accommodations for persons at higher risk for severe
illness per CDC guidelines (these guidelines are available at:
https://www.cdc.gov/coronavirus/2019-ncov/faq.html#Higher-Risk).
• Businesses must require sick workers to stay at home or go home if they start to have
symptoms.
• Businesses must have COVID-19 testing information readily available for employees
including testing location information.
• Employers must educate and train all individuals including employees, temporary
employees, contractors, vendors, customers, etc., regarding Healthy at Work protocols.
Employers must communicate with employees any industry, company, and/or site/job
specific plans, guidelines and requirements. Any updates must also be shared to ensure
understanding and compliance. All education and training must be communicated in the
language best understood by the individual receiving the education and training.
Businesses should post signage at employee entrances and/or where other essential
employee information is posted such as bulletin boards on construction sites.
VERSION 1.1– Effective May 11, 2020
Requirements for Manufacturing, Distribution, and Supply

Chain Businesses
In addition to the Healthy at Work Minimum Requirements, manufacturing,
distribution, and supply chain businesses must meet the requirements below in
order to reopen and remain open:

• Businesses must ensure that each employee is able to maintain six (6) foot distance
between themselves and others for their entire shift. Controls must be established and
maintained when six (6) feet of physical distancing is not feasible. This includes
installation of portable or permanent non-porous physical barriers (e.g., plexiglass
shields), high-efficiency air filters, increased ventilation, or PPE. Production practices
should be modified, to the greatest extent practicable, to enforce adequate social
distancing.
• Businesses should, to the greatest extent practicable, stagger the schedules for work
shifts, breaks, and lunches to reduce the number of employees on-site, entering, exiting,
or gathering at one time. This also reduces the number of employees simultaneously
reporting to time clock stations to record their work and break time.
• Businesses should temporarily eliminate use of any high-touch time clock system(s).
• Businesses should seek to limit activities that require employees to enter within six (6)
feet or less of another person, regardless of whether they have installed non-porous,
physical barriers.
• Businesses must ensure that all gatherings are kept to a minimum, appropriate social
distancing is observed at all times, and meetings are held by telephone or video
conferencing to the greatest extent practicable.
• Businesses must restrict access to common areas in order to maximize social distancing
and reduce congregating. These common areas include, but are not limited to, waiting
rooms, breakrooms, water fountains, and vending areas. Businesses restricting access to
water fountains must provide alternative water sources for employees in lieu of water
fountains.
• Businesses must ensure minimal interaction between drivers at loading docks, doorsteps,
or other locations.
• Businesses must reduce traffic and congregating, to the greatest extent practicable, in
locker rooms and changing rooms. Lockers may be used but should be cleaned and
sanitized consistent with CDC guidelines. Lockers should not be shared.
• Businesses must ensure, where applicable, limitations on use and number of people riding
in a vehicles together. If more than one person in a vehicle is unavoidable, then
employees should maximize social distancing and wear face masks in the vehicle.
Employers are required to thoroughly sanitize company vehicles after any employees
were inside.

• Businesses must ensure cleaning and sanitation of frequently touched equipment, tools,
objects, and surfaces with appropriate disinfectants. Appropriate disinfectants include
EPA registered household disinfectants, diluted household bleach solution, and alcohol
solutions containing at least 60% alcohol. Businesses must establish a cleaning and
suspected, or confirmed COVID-19 case.
• Businesses must ensure that shared touched surfaces must be cleaned on a recurring
basis consistent with CDC guidelines. This includes, but is not limited to:
vehicle/equipment door handles; keys; gear shifts; steering wheel/operator controls and
levers; door knobs; light switches; phones; computers/keyboards; copiers; elevator
buttons; toilets; faucets; sinks; countertops; paper towel dispensers; desktops; handrails;
counters; tables; and cabinets and knobs.
• Businesses must ensure that employees wipe their workstations down with disinfectant
at the end of their shift or at any time they discontinue use of their workstations for a
significant period of time.
• Businesses must ensure that disinfecting wipes or other disinfectant are available at
shared equipment.
• Businesses, as appropriate, must ensure that workers do not use cleaning procedures that
chemicals.

• Businesses must ensure that appropriate face coverings and other personal protective
equipment (PPE) is used by employees so long as such use does not jeopardize the
employees’ health or safety. Businesses must train employees to use PPE. This training
includes: when to use PPE; what PPE is necessary; and how to properly put on, use, and
remove PPE.
• Businesses must train employees to properly dispose of or disinfect PPE, inspect PPE for
damage, maintain PPE, and the limitations of PPE.
• Businesses should follow CDC, OSHA, and other federal guidelines relating to gloves for
managers and employees.
Training and Safety Requirements for Manufacturing Businesses
• Businesses should make available and post information to reinforce Healthy at Work
requirements. Businesses must provide special accommodations for employees for
persons at higher risk for severe illness per CDC guidelines. These guidelines are available
at: https://www.cdc.gov/coronavirus/2019-ncov/faq.html#Higher-Risk
• Businesses should ensure that employees are instructed to avoid touching their faces,
including their eyes, noses, and mouths, particularly until after they have thoroughly
washed their hands upon completing work and/or removing PPE, to the greatest extent
practicable.
• Businesses should ensure that employees are informed that they may identify and
communicate potential improvements and/or concerns in order to reduce potential risk
of exposure at the workplace. All education and training must be communicated in the
Requirements for Office-Based Businesses1

In addition to the Healthy at Work Minimum Requirements, office-based
open:

• Businesses should conduct business via phone or Internet to the greatest extent practicable.
Employees who are currently able to perform their job duties via telework should continue to
telework.
• Businesses must ensure that no more than 50% of employees are physically present in the office
on any given day.
• Businesses must ensure that employees wear face masks for any interactions between co-workers
or while in common travel areas of the office (e.g., hallways, conference rooms, bathrooms,
entries and exits). Employees are not required to wear face masks while alone in personal offices
or if doing so would pose a serious threat to their health or safety.
• Businesses should ensure that employees use digital files rather than paper formats (e.g.,
documentation, invoices, inspections, forms, agendas) to the greatest extent practicable.
• Businesses must conduct meetings with customers over the phone or Internet to the greatest
extent practicable. Where in-person meetings with customers cannot be avoided, the employees
must wear face masks and remain six feet apart from the customers.
• Businesses should, to the greatest extent practicable, modify the office’s traffic flow to minimize
contacts between employees.

• Businesses should ensure that offices and workstations are properly cleaned and ventilated.
• Businesses should encourage employees to frequently wash their hands or use hand sanitizer,
which should be provided by the business.
1
Office-based businesses include finance and accounting, legal, insurance, engineering, architecture, real estate,
scientific/technical, property management, non-profit organizations performing administrative services, and other
corporate offices and private office-based firms.

• Businesses should ensure that appropriate signage is posted throughout the office space to
inform employees and customers about good hygiene and new office practices.
• Businesses should, to the greatest extent practicable, implement hours where service can be
safely provided to persons at higher risk for severe illness per CDC guidelines. These guidelines
are available at:https://www.cdc.gov/coronavirus/2019-ncov/faq.html#Higher-Risk
Requirements for Pet Care, Grooming, and Boarding Businesses
In addition to the Healthy at Work Minimum Requirements, pet care, pet

grooming, and pet boarding businesses must meet the requirements below in
order to reopen and remain open:

• Businesses should notify any customer dropping-off or picking-up pets that the customer
must remove their pet’s leash and collar and deliver their pet either curbside, in a crate,
or in an entry room to avoid interaction. Employees can then retrieve the pet. Pet care
businesses should ensure that the reverse procedure is followed during pickup.
• Businesses should communicate with clients and receive payments via phone or Internet.
• Businesses should ensure that their employees use the business’s equipment (such as the
business’s leashes, collars, and beds) rather than using the customers’ equipment. Pet
business equipment must be sanitized after each use.
• Businesses should ensure employees wash their hands for a minimum of twenty (20) seconds
before and after contact with pets.
Guidelines for Vehicle and Boat Dealerships

In addition to the Healthy at Work minimum requirements, vehicle and boat
dealerships must meet the requirements below in order to reopen and remain
open:

• Dealerships should prioritize digital and online sales.
• Dealerships should communicate with customers over the phone or Internet to the
• Dealerships, should limit access to showrooms to ensure both customers and employees
are able to remain six feet or more apart. In no case should a showroom exceed 25% of
its designated maximum occupancy. For some showrooms, it may be necessary for
dealerships to set a limit below 25% of its designated maximum occupancy to ensure
proper social distancing.
• Dealerships should allow customers to test drive vehicles/vessels without an employee

present in order to ensure social distancing. Vehicles/vessels should be thoroughly
sanitized after each test drive.
• Dealerships should ensure that all sales paperwork can be completed electronically to the
greatest extent practicable by using Docusign or other e-signature technology for
signatures.
• Dealerships should ensure that, if there are any documents that must be completed in
person, there is a safe process for doing so. This includes compiling all sales paperwork
that must be completed in person and leaving it in a single room for the customer to
complete alone.
• Dealerships should ensure that all deliveries occur without personal interaction.
Deliveries should be made curbside, at the customer’s home, or in open service lanes.

• Dealerships should ensure that vehicles/vessels and corresponding keys are thoroughly
sanitized prior to delivery.
• Dealerships should encourage customers to re-sanitize the keys and high-touch areas of
the interior of the vehicle or vessel upon taking possession.
Requirements for Horse Racing Tracks

In addition to the Healthy at Work Minimum Requirements, horse racing tracks

• Racetracks may permit only authorized employees, Kentucky Horse Racing Commission
license holders who have a horse stabled at a racetrack, and those providing support for
a horse stabled at a racetrack at the racetrack. This includes, but is not limited to,
racetrack employees, trainers, assistant trainers, exercise riders, grooms, hot walkers,
jockeys, veterinarians, farriers, and feed vendors.
• Racetracks must prohibit fans and outside media.
• Racetracks must ensure that employees and those providing support for a horse stabled
at the racetrack may not bring guests, including family members.
• Racetracks must ensure, to the greatest extent practicable, that persons supporting a
horse stabled at a racetrack remain in their assigned barns, dormitories, or tack houses,
except when going to and from the track, laundry facilities, bathroom and bathing
facilities, and kitchens or dining facilities for the purpose of food carry-out or pick-up.
• Racetracks must, to the greatest extent practicable, stagger normal procedures (e.g.,
horse shipping/arrival, employee gate entry, weighing in/out, showering) to ensure that
employees do not congregate. Racetracks should ensure that employees and other
persons present abide by appropriate social distancing requirements.
• Racetrack saunas and steam rooms and workout rooms will remain closed.
• Racetrack must ensure racetrack kitchens or other food facilities on the premises provide
food via-carry out or curbside pick-up.
• Racetracks shall ensure, to the greatest extent practicable, that racing, grooming, and training
equipment (e.g. lead shanks, grooming tools, mucking equipment, tack) is not shared. Racetracks
shall further ensure that shared and other high-touch equipment and surfaces be appropriately
disinfected between uses.
Requirements for Photography Businesses

In addition to the Healthy at Work Minimum Requirements, photography
open:

• Photographers should avoid photographing groups outside of family units and in no case
groups larger than ten individuals as long as mass gatherings remain prohibited.
• Photographers should remain six feet or farther from all subjects and employ zoom
settings for up-close photographs.
• Subjects who are not living in the same household must pose at least six feet or farther
apart (i.e. persons living in different households should not pose next to one another).
• Photography sessions should be held outside unless an in-studio session is absolutely

necessary.
• Photographers should ensure, to the greatest extent practicable, that all scheduling,
communication, preview of photographs, and payments take place electronically.
• Photographers should wear a recently washed mask to the greatest extent practicable.
• For in-studio sessions, all high contact areas (e.g. doorknobs or items used to pose in
photos) should be sanitized before and after each photo session.
Requirements for Funeral and Memorial Services

Funeral and memorial service providers will be required to meet the same Healthy
at Work Minimum Requirements as businesses. In addition funeral and memorial
service providers must meet the requirements below in order to reopen and
remain open:

• Funeral and memorial service providers conducting in-person funerals, memorials or
burials should limit attendance to no more than 33% of the building occupancy capacity,
excluding any officiants, funeral directors, clergy and staff members, while maintaining
social distance between household units of at least six (6) feet. A funeral or memorial
service provider that cannot maintain this space must further reduce occupancy capacity
until this is achieved. Additionally, funeral and memorial service providers should, to the
greatest extent practicable, conduct alternative services, including recorded video and
live video internet broadcasted services (e.g. live streaming social media broadcasts).
• Funeral and memorial service providers, for outdoor funerals, memorials or graveside
services, should encourage services which allow their attendees remain in their vehicles
and not socialize through their vehicle windows, except at a distance of more than six (6)
feet. Attendees should turn off their vehicles to avoid idling and protect everyone’s
health. If drive-up outdoor services are not possible, attendees to an outdoor service must
maintain of at least six feet of social distance, if they are not of the same household.
• Funeral and memorial service providers should ensure, to the greatest extent practicable,
that officiants, funeral directors, clergy, staff-employees, and service attendees wear
coverings (e.g., cloth mask or bandana) over their mouths and noses while attending
services.
• Funeral and memorial service providers should, to the greatest extent practicable, limit
congregational singing during services, as doing so may aerosolize infectious particles. To
the extent practicable, funeral and memorial providers should consider alternatives to
congregational singing, including by playing pre-recorded or live instrumental music (e.g.
pianos and guitars - no wind instruments) during services.
• Funeral and memorial service providers should consider taking attendees’ temperatures
and asking about signs of illness before admitting them into the funeral home, house of
worship or other buildings where funeral or memorial services are held.
• Funeral and memorial service providers should not allow individuals with elevated
temperatures or signs of illness (coughing, runny nose, sneezing) to attend in-person
services. Funeral and memorial service providers should direct those having symptoms of
COVID-19, as well as people who have had close contact with a person who has symptoms
like dry cough, chest tightness, and/or fever, to refrain from participating in any aspect of
in-person services and stay at home or seek immediate medical care.
• Funeral and memorial service providers making restrooms available must ensure
restrooms are only used by one person at a time and high touch surfaces are
appropriately disinfected after each use (e.g. door knobs and handles).
• Funeral and memorial service providers conducting in-person services must, to the
greatest extent practicable, provide hand sanitizer, handwashing facilities, tissues and
waste baskets in convenient locations.
• Funeral and memorial service providers should not provide communal food or beverages
to officiants, funeral directors, clergy, staff-employees, or attendees.
• Funeral and memorial service providers should restrict access to common areas, to the greatest
extent practicable, in order to maximize social distancing and reduce congregating. These
common areas include, but are not limited to, foyers, lobbies, vending areas, and community
and multi-purpose rooms. Funeral and memorial service providers should arrange seating that
allows for social distancing of at least six feet separation between family or same household
attendees.
• Funeral and memorial service providers should, to the greatest extent practicable, find
and encourage alternatives to handshaking, handholding and hugging.
• Funeral and memorial service providers should encourage those at higher risk for severe
illness per CDC guidelines not to attend in-person services. These guidelines are available
at: https://www.cdc.gov/coronavirus/2019-ncov/faq.html#Higher-Risk. Instead, funeral
and memorial service providers should, to the greatest extent practicable, provide
alternative services, including live streaming social media broadcasts. If a funeral or
memorial service provider is unable to provide alternative services, they should, to the
greatest extent practicable, implement hours where service can be safely provided to
congregants at higher risk for severe illness.
• Funeral service providers should encourage funeral directors, staff and pallbearers to take
precautions to stay safe while they are in close proximity to one another while honoring
the deceased (e.g. wearing masks and minimize verbal interaction).

• Funeral and memorial service providers should ensure facilities are properly cleaned and
ventilated.
• Funeral and memorial service providers must ensure cleaning and sanitation of frequently
touched surfaces with appropriate disinfectants. Appropriate disinfectants include EPA
registered household disinfectants, diluted household bleach solution, and alcohol
solutions containing at least 60% alcohol. Funeral and memorial service providers must
establish a cleaning and disinfecting process that follows CDC guidelines when any
individual is identified, suspected, or confirmed as COVID-19 positive.
• Funeral and memorial service providers, as appropriate, must ensure they do not use
cleaning procedures that could re-aerosolize infectious particles. This includes, but is not
limited to, avoiding practices such as dry sweeping or use of high-pressure streams of air,
water, or cleaning chemicals.
• Funeral and memorial service providers should put into place protocols to reduce or
eliminate repeat touching of surfaces by officiants, funeral directors, clergy, staff-
employees and attendees (e.g. flowers or flower arrangements, microphones, doors and
door knobs or handles). If alternative expressions of support (e.g. donations to charitable
organizations representing a cause the deceased or their family supports) would aide in
reducing repeat touching then funeral or memorial service providers should consider
encouraging those options.

• Funeral and memorial service providers should ensure appropriate signage is posted
throughout their facilities to inform officiants, funeral directors, clergy, staff-employees,
and congregants about good hygiene and new practices.
• Funeral and memorial service providers should ensure officiants, funeral directors, clergy,
staff-employees, and congregants are instructed to avoid touching their faces, including
their eyes, noses, and mouths, particularly until after they have thoroughly washed their
hands upon completing work and/or removing PPE, to the greatest extent practicable.
• Funeral and memorial service providers should ensure officiants, funeral directors, clergy,
staff-employees, and congregants are informed that they may identify and communicate
potential improvements and/or concerns in order to reduce potential risk of exposure.
Guidance for Gatherings of Up To Ten (10) People

• Under Governor Beshear’s new executive order, groups of up to ten (10) people may
begin gathering on May 22, 2020.
• Public health experts recommend people remain Healthy at Home to the greatest
extent practicable and that they continue to socialize via Internet, telephone, and any
other modes of communications that allow people to engage in appropriate social
distancing.
• While people may meet in groups of up to ten (10) people, public health experts
discourage people from engaging in excessive social gatherings in order to
appropriately limit contacts.
• If people meet in the allowable groups of up to ten (10) people, public health experts
recommend limiting the gathering size to the smallest number of people practicable.
• Public health experts discourage people from sharing items in any gathering, including
tools, sporting equipment, vehicles, cooking/grilling ware, and other high-touch
objects.
• If you are a member of a group particularly vulnerable to COVID-19 (individuals with

conditions identified by the CDC as higher risk or those over 65 years old), public
health experts recommend that you avoid any in-person gatherings and remain
Healthy At Home.
• If you host or attend a gathering of up to ten people, please consider the following
recommendations:
o Hold the gathering outside whenever possible;
o Remain at least six (6) feet apart from people who are not a part of your
household;
o Do not share food, drink, containers, plates, napkins, or utensils;
o Wash or sanitize your hands frequently before, during, and after the
gathering;
o Avoid touching your eyes, nose, or mouth, and;
o If you will be closer than six (6) feet to someone outside your household at any
point, wear a cloth face covering or mask over your nose and mouth.
Guidelines for Places of Worship

Places of worship will be expected to meet the Healthy at Work Minimum
Requirements. In addition, places of worship should follow the guidelines in order
to reopen and remain open:
Social Distancing
• Places of worship should, to the greatest extent practicable, continue to conduct
alternative services, including tele-services, radio broadcasts, and drive-in services.
• Places of worship conducting drive-in services should ensure their congregants remain in
their vehicles and not socialize through their vehicle windows, except at a distance of
more than six (6) feet. Attendees should turn off their vehicles to avoid idling and protect
everyone’s health.
• Places of worship conducting in-person services should limit attendance to no more than
33% of the building occupancy capacity, including clergy and staff-employees, while
maintaining social distance between household units of at least six (6) feet. This means
that there must be six (6) feet between individuals on a row and individuals between
rows, such that a six-foot radius is maintained around all household units. A place of
worship that cannot maintain this space must further reduce its occupancy capacity until
it is achieved.
employees, volunteers and congregants wear coverings (e.g., cloth mask or bandana)
• Places of worship should wait to reopen youth services (including, but not limited to,
Sunday schools) until childcare services have reopened on June 15, 2020. Once they
reopen, youth services should follow the requirements posted for childcare services.
• Singing during services creates a higher risk of spreading infectious particles. Choirs
should avoid singing. Congregants should wear face coverings and consider a greater than
six feet social distance from others if they choose to sing. Houses of worship should
consider alternatives to congregational singing, including by playing pre-recorded or live
instrumental music (e.g. pianos and guitars - no wind instruments) during services.
• Places of worship should consider taking congregants’ temperatures and asking about
signs of illness before admitting them into the place of worship. If they do take
temperatures, they should consider using a non-contact thermometer or thermal imager.
If a place of worship must use a standard oral/aural thermometer, consider having the
congregant take their own temperature and relay the information to maintain social
distancing and sanitize the thermometer after each use.
• Places of worship should not allow individuals with elevated temperatures (100.5 degrees
Fahrenheit or above) or signs of illness (coughing, shortness of breath, sneezing) to attend
in-person services. Houses of worship should direct those having symptoms of COVID-19,
as well as people who have had close contact with a person who has symptoms like dry
cough, chest tightness, and/or fever, to refrain from participating in any aspect of in-
person services. Places of worship should encourage symptomatic persons to stay at
home, seek immediate medical care, or get tested.
• Places of worship should use greeters to direct congregants to available masks and
bulletins. Greeters should be masked, maintain social distancing, and consider wearing
gloves.
• Places of worship should display markers and signage in the sanctuary/meeting space to
guide social distancing.
• Places of worship should communicate with the congregation often and with clarity and
transparency. Prepare the congregation for worship and for the changes that are
occurring in procedures due to the national health crisis.
• Places of worship making restrooms available must ensure restrooms are only used by
one person at a time and all portions that are regularly touched (e.g., door, sink, and toilet
handles) are appropriately disinfected after each use.
• Places of worship conducting in-person services must, to the greatest extent practicable,
provide hand sanitizer, handwashing facilities, tissues, and waste baskets in convenient
locations.
• Places of worship should not provide communal food or beverages to clergy, staff-
employees, volunteers, or congregants.
• Places of worship should restrict access to common areas, to the greatest extent
common areas include, but are not limited to, foyers, lobbies, vending areas, community
and multi-purpose rooms, and event spaces.
• Because of the requirement to socially distance at least six (6) feet apart, places of
worship should refrain from the practice of handshaking, handholding, or hugging.
• Places of worship should encourage those at higher risk for severe illness per CDC
guidelines not to attend in-person services. These guidelines are available
at:https://www.cdc.gov/coronavirus/2019-ncov/faq.html#Higher-Risk. Instead, places of
worship should, to the greatest extent practicable, provide services that are not in-
person, including tele-services, drive-in services, and/or radio services for those
individuals. If a house of worship is unable to provide alternative services, they should,
to the greatest extent practicable, implement hours where service can be safely provided
to congregants at higher risk for severe illness.
Personal Protective Equipment Requirements

employees, volunteers and congregants wear face coverings (e.g., cloth mask or bandana)

• Places of worship must ensure facilities are properly cleaned and ventilated.
• Places of worship must ensure cleaning and sanitation of frequently touched surfaces
with appropriate disinfectants. Appropriate disinfectants include EPA registered
containing at least 60% alcohol. Places of worship must establish a cleaning and
suspected, or confirmed as COVID-19 positive.
• Places of worship, as appropriate, must ensure they do not use cleaning procedures that
chemicals.

• Places of worship should ensure appropriate signage is posted throughout their facilities
to inform clergy, staff-employees, and congregants about good hygiene and new
practices.
instructed to avoid touching their faces, including their eyes, noses, and mouths,
particularly until after they have thoroughly washed their hands upon completing work
and/or removing PPE, to the greatest extent practicable.
concerns in order to reduce potential risk of exposure.
Requirements for Retail Businesses

In addition to the Healthy at Work Minimum Requirements, retail businesses must
meet the requirements below in order to reopen and remain open:

• Retail businesses should provide services and conduct business via phone or Internet to the
greatest extent practicable. Any retail employees who are currently able to perform their job
duties via telework (e.g., accounting staff) should continue to telework.
• Retail businesses must limit the number of customers present in any given retail business
to 33% of the maximum permitted occupancy of the facility, assuming all individuals in
the store are able to maintain six (6) feet of space between each other with that level of
occupancy. If individuals are not able to maintain six (6) feet of space between each other
at 33% of capacity, the retail business must limit the number of individuals in the store to
the greatest number that permits proper social distancing.
• If a retail business has more customers wishing to enter their business than is possible
under the current social distancing requirements of six (6) feet between all individuals,
the business should establish a system for limiting entry and tracking occupancy numbers.
Once a retail business has reached its capacity, it should permit a new customer inside
only after a previous customer has left the premises on a one-to-one basis. Retail
businesses experiencing lines or waits outside their doors should establish a safe means
for customers to await entry, such as asking customers to remain in their car and notifying
them via phone when they are able to enter the store or marking off spots six (6) feet
apart where customers can safely stand without congregating.
• Retail businesses should ensure employees wear face masks for any interactions between
co-workers or while in common travel areas of the business (e.g., aisles, hallways, loading
docks, breakrooms, bathrooms, entries and exits). Retail employees are not required to
wear face masks while alone in personal offices or if doing so would pose a serious threat
to their health or safety.
• Retail businesses should ensure employees use digital files rather than paper formats
(e.g., documentation, invoices, inspections, forms, agendas) to the greatest extent
practicable.
• Retail businesses should, to the greatest extent practicable, modify internal traffic flow to
minimize contacts between employees and customers.
• Retail businesses should demarcate six feet of distance between customers, cashiers, and
baggers, except at the moment of payment and/or exchange of goods. Retail businesses
should seek to limit activities that require employees to enter within six (6) feet or less of
another person, regardless of whether they have installed non-porous, physical barriers.
Retail businesses should establish controls, to the greatest extent practicable, when six
(6) feet of physical distancing is not feasible. This includes, for example, installation of
portable or permanent non-porous physical barriers (e.g., plexiglass shields) at cash
registers and point of sale.
• Retail businesses should implement contactless payment options, pickup, and delivery of
goods to the greatest extent practicable.
• Retail businesses should ensure, to the greatest extent practicable, that any paperwork
can be completed electronically by using e-signature technology for signatures.
• Retail businesses should ensure, if there are any documents that must be completed in-
person, there is a safe process for doing so. This includes compiling all paperwork that
must be completed in-person and leaving it in a single room for the customer to complete
alone. Providing a sanitized pen for customer should also be included.
• Retail businesses should reduce, to the greatest extent practicable, the number
employees and customers entering, exiting, or gathering at one time. One suggested
method to accomplish this is by staggering the beginning and end times of employee
shifts.Retail businesses that require employees to operate equipment or vehicles must,
to the greatest extent practicable, limit the number of employees riding in the vehicle
together. If riding in separate vehicles is not practicable then employees should maximize
social distancing and wear face masks in the vehicle. Thorough cleaning and disinfecting
vehicles after each trip is required.
• Retail businesses must restrict access to common areas, to the greatest extent
common areas include, but are not limited to, break rooms, food courts, public seating,
and vending areas.
• Retail businesses with warehouses and loading docks must ensure minimal interaction
between drivers at loading docks, doorsteps, or other locations.
• Retail businesses making restrooms available should, to the greatest extent practicable,
limit the number of individuals in a restroom to ensure proper social distancing and
ensure that frequently touched surfaces are appropriately disinfected (e.g., door knobs
and handles).
• Retail businesses should provide hand sanitizer, handwashing facilities, and tissues in
convenient locations to the greatest extent practicable.
• Retail businesses should limit the number of delivery personnel working together at one
time to the greatest extent practicable.
• Retail businesses must ensure six (6) feet of distance between employees and customers
during in-home deliveries and installations.
• Retail businesses should prohibit gatherings or meetings of employees of ten (10) or more
during work hours, and should instead permit employees to take breaks and lunch
outside, in their office or personal workspace, or in other areas where proper social
distancing may be accomplished.
• Retail businesses should discourage employees from sharing phones, desks, workstations,
radios, handhelds/wearables, or other work tools and equipment to the greatest extent
practicable.
• Retail businesses should extend the time period for customers to return items.
• Retailer businesses should not allow sampling and customer access to bulk-bins.
• Retail businesses should, to the greatest extent practicable, install floor decals in cashier
and queuing areas to establish safe waiting distance.
• Retail businesses should close public seating areas.
• Retail businesses should close childrens’ play areas.
• Retail businesses should discourage customers from using items prior to sale, other than
apparel items. However, any item that has been used or tried on must be sanitized before
it is returned to the sales floor.
• Retail businesses should encourage customers to touch only those items that they intend
to buy.
• Retail businesses should disallow any make-up application stations or other cosmetic
facilities that encourage people to congregate.
• Retail businesses should establish procedures for managing fitting rooms, including
sanitation and social distancing requirements.
• Retailer businesses should limit fitting rooms to one customer at a time to the greatest
extent practicable.
• Retailer businesses should ensure any items that are not purchased are set aside in
compliance with retailer established guidelines for returns. Items, such as apparel, tried
on but not purchased would be separated and cleaned using steam or other appropriate
cleaning measures prior to returning to sales floor.

• Retail businesses should ensure that offices and workstations are properly cleaned and
ventilated.
• Retail businesses should encourage employees to frequently wash their hands or use
hand sanitizer, which should be provided by the retail business.
• Retail businesses must ensure that cleaning and sanitation of frequently touched surfaces
with appropriate disinfectants. Areas with frequently touched surfaces include fitting
rooms, doors, PIN pads, and common areas. Appropriate disinfectants include EPA
registered household disinfectants, diluted household bleach solution, and alcohol
solutions containing at least 60% alcohol. Retail businesses must establish a cleaning and
suspected, or confirmed COVID-19 case.
• Retail businesses should ensure shopping carts and baskets are sanitized after each use.
• Retail businesses should ensure employees wipe their workstations/cash registers down
with disinfectant at the end of their shift or at any time they discontinue use of their
workstations/cash register for a significant period of time.
• Retail businesses should ensure disinfecting wipes or other disinfectant are available near
shared equipment.
• Retailer businesses should encourage customers to use hand sanitizer or wipes prior to
fitting room use.
• Retail businesses should ensure employees do not use cleaning procedures that could re-
aerosolize infectious particles. This includes, but is not limited to, avoiding practices such
as dry sweeping or use of high-pressure streams of air, water, or cleaning chemicals.
• Retail businesses must ensure employees, for their own safety and that of the customer,
clean and disinfect any surfaces which will be regularlytouched throughout the duration
of any in-home installation.
• Retail businesses must ensure the employee cleans and disinfect all surfaces which were
contacted throughout in-home deliveries and installations.
• Retail businesses must ensure employees clean and disinfect any tools or supplies used
through delivery andinstallation upon leaving the home.
• Retailers should clean all fitting rooms prior to use.

• Retail businesses must ensure appropriate face coverings and other personal protective
equipment (PPE) is used by employees whenever they are near other employees or
customers so long as such use does not jeopardize the employees’ health or safety. Retail
businesses must train employees to use PPE. This training includes: when to use PPE; what
PPE is necessary; and how to properly put on, use, and remove PPE. Retail business shall
provide employees with face coverings.
• Retail businesses must require contractors, vendors, and drivers to wear face coverings or
masks while at the retail location.
• Retail businesses should establish a policy as to whether to serve customers who do not
adhere to the business’s policy on requiring masks. Retail businesses may choose not to
serve those customers who refuse to wear a mask in order to protect their employees and
other customers.
• Retail business must train employees to properly dispose of or disinfect PPE, inspect PPE
for damage, maintain PPE, and the limitations of PPE.
• Retail businesses must ensure, to the greatest extent practicable, that employees use
gloves, along with any PPE normally used for routine job tasks, when cleaning equipment,
workspaces, and high-touch areas of the business.
• Retail businesses must ensure gloves are available to employees engaging in high-touch
• Retail businesses must ensure employees wear gloves while handling products during
shipping and receiving.
• Retail businesses must ensure employees wear protective face coverings and gloves
during any in-home delivery.

• Retail businesses must place conspicuous signage at entrances and throughout the store
alerting staff and customers to the required occupancy limits, six feet of physical distance,
and policy on face coverings. Signage should inform employees and customers about
good hygiene and new practices.
• Retail businesses should establish procedures for processing, handling, and disinfecting
returns and exchanges before returning items to the sales floor.
• Retail businesses should, to the greatest extent practicable, implement hours where
service can be safely provided to customers at higher risk for severe illness per CDC
guidelines. These guidelines are available at:https://www.cdc.gov/coronavirus/2019-
• Retail businesses should ensure employees are informed that they may identify and
CA BI NE T F O R HE ALT H AN D F AM I L Y S E RV I CE S
O FFI CE O F TH E S E CRE TA RY
Andy Beshear 275 East Main Street, 5W-A Eric C. Friedlander

Governor Frankfort, KY 40621 Secretary
502-564-7042
502-564-7091
www.chfs.ky.gov
ORDER
June 3, 2020
On March 6, 2020, Governor Andy Beshear signed Executive Order 2020-215, declaring a state of
emergency in the Commonwealth due to the outbreak of COVID-19 virus, a public health emergency.
Pursuant to the authority in KRS 194A.025, KRS 214.020, and Executive Orders 2020-215 and 2020-
323, the Cabinet for Health and Family Services, Department for Public Health, hereby orders the
following directives to reduce and slow the spread of COVID-19:
1. The May 22, 2020 Order of the Cabinet for Health and Family Services that
amended the March 16, 2020 Order of the Cabinet for Health and Family Services
concerning restaurants (the “March 16 Food and Beverage Order”) and the March
17, 2020, Order of the Cabinet for Health and Family Services concerning public-
facing businesses (the “March 17 Public-Facing Businesses Order”) is hereby
amended as follows.
2. Effective June 1, 2020, the March 17, 2020 Public-Facing Businesses Order
(as amended) shall no longer apply to the following businesses or entities: (1)
Auctions; (2) Auto/Dirt track racing; (3) Aquatic centers; (4) Bowling alleys; (5)
Fishing tournaments; (6) Fitness centers; and (7) Movie theaters. Effective June 3,
2020, the March 17, 2020 Public-Facing Businesses Order (as amended) shall no
longer apply to the miniature golf businesses or entities. The businesses or entities
identified in sections (1) through (7) of this paragraph must, in addition to the
minimum requirements for all entities in the Commonwealth of Kentucky
attached to and incorporated by reference in the May 11, 2020 Order of the
Cabinet, implement and follow the specific Requirements for each respective
business or entity, which are attached hereto and fully incorporated by reference
herein. Miniature golf businesses or entities must implement and follow the
minimum requirements for all entities in the Commonwealth attached to and
incorporated by reference in the May 11, 2020 Order of the Cabinet. The specific
Kentucky.gov An Equal Opportunity Employer M/F/D

Case: Requirements for each business
3:20-cv-00036-GFVT Doc #:identified in sections
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paragraph and the minimum requirements for all entities are available online at:
https://healthyatwork.ky.gov.
3. The March 17, 2020 Public-Facing Businesses Order (as amended) otherwise
remains in effect except as amended by the May 22, 2020 Order and this Order.
4. The March 16, 2020 Food and Beverage Order (as amended) otherwise remains
in effect except as amended by the May 22, 2020 Order.
5. Establishments and public-facing businesses that encourage public

congregation or that, by the nature of the service to the public, cannot comply
with CDC guidelines concerning social distancing, that were ordered to cease all
in-person operations under the March 16, 2020 Food and Beverage Order or the
March 17, 2020 Public-Facing Businesses Order remain prohibited from
conducting all in-person operations unless otherwise provided in May 22, 2020
Order and this Order.
6. For the avoidance of doubt, all public facing-businesses permitted to operate

must to the extent practicable implement Centers for Disease Control guidance,
including:
• ensuring employees practice appropriate hygiene measures, including

regular, thorough handwashing;
• ensuring that employees who are sick remain home; and
• regularly cleaning and disinfecting frequently touched objects and

surfaces.
7. Failure to follow the requirements provided in this Order and any other
Executive Order and any Cabinet Order, including but not limited to the Orders of
the Cabinet for Health and Family Services, is a violation of the Orders issued
under KRS Chapter 39A, and could subject businesses to closure or additional
penalties as authorized by law.
8. The Department for Public Health hereby delegates to local health departments
the authority to take all necessary measures to implement this Order.
The Secretary for the Cabinet for Health and Family Services has been designated by the Governor to
deliver these directives during this public health emergency. The Cabinet for Health and Family
Services will continue to provide information and updates during the duration of this Public Health
Emergency. Prior orders of the Cabinet for Health and Family Services remain in effect unless
inconsistent with this Order.
VERSION 1.0 – Effective June 1, 2020
Requirements for Auctions

In addition to the Healthy at Work Minimum Requirements, auctions
Social Distancing Requirements for Auctions

• Auctions must continue to be held online or remotely to the greatest extent practicable.
• For those auctions that cannot be held remotely, they must be held outside to the greatest
extent practicable.
• For those auctions that cannot be held remotely or outdoors, auctions must limit the number of
customers present in any auction space to 33% of the maximum permitted occupancy of the
facility, assuming all individuals in the space are able to maintain six (6) feet of space between
each other with that level of occupancy. If individuals are not able to maintain six (6) feet of
space between each other at 33% of capacity, auctions must limit the number of individuals in
the space to the greatest number that permits proper social distancing.
• Auctions must ensure that all participants remain a minimum of six (6) feet away from each
other and any auctioneers or staff. This includes during sign-in, previewing of the auction items,
bidding, picking up items, and submitting payment. Chairs, if used, should be placed six (6) feet
apart from one another to ensure proper social distancing.
• Auctions cannot serve food or drink.
• Auctions must ensure customers can pick up purchased items one person at a time and
without in-person interaction, either by appointment or by establishing a designated
space where each purchased item will be left for pickup.
• Auctions must use online registration, sign-in, and payment to the greatest extent
practicable. For sign-ins or other documents that must be done in person, auctions must
establish a system that minimizes in-person interaction to the greatest extent practicable,
such as providing a designated space where one person at a time can sign documents.
• Auctions must stagger set-up, check-in, entry, exit, and breakdown times to avoid
customers and auction staff congregating.
Cleaning and Disinfecting Requirements for Auctions
• Auctions that cannot be held remotely or outside must ensure that their facilities,
including breakrooms and restrooms, are properly cleaned and ventilated. Auctions that
cannot be held outside are encouraged to open exterior doors and windows to increase
ventilation.
• Auctions should provide hand sanitizer, handwashing facilities, tissues and waste baskets
in convenient locations to the greatest extent practicable.
• Auctions must limit the use of shared equipment or items (e.g., pens, documents, bid
paddles) to the greatest extent practicable. Any items that must be shared must also be
thoroughly disinfected between each use.
• Auctions must limit touching of auction items to the greatest extent practicable. For
those auction items that must be touched, they must be disinfected after each use if doing
so is possible and would not diminish the quality or value of the item.
• Auctions making restrooms available must ensure frequently touched surfaces are
frequently cleaned and disinfected (e.g., door knobs and handles).
Personal Protective Equipment (PPE) Requirements for Auctions

• Auctions must ensure that all staff wear facemasks or other face coverings whenever they
are within six (6) feet of another person unless doing so would represent a serious risk to
the staff member’s health or safety.
• Auctions may require customers to wear masks as well. Auctions should establish a policy
as to whether to serve customers who do not adhere to the business’s policy on requiring
masks. Auctions may choose not to serve those customers who refuse to wear a mask in
order to protect their employees and other customers.
• For those auction items that must be touched and cannot be properly disinfected, auction
staff and customers must wear gloves while examining the item and properly dispose of
those gloves immediately after.
Training and Safety Requirements for Auctions
• Auctions must train staff to use PPE. This training includes: when to use PPE; what PPE is
necessary; how to properly put on, use, and remove PPE; how to properly dispose of or
disinfect PPE; how to inspect PPE for damage; how to maintain PPE, and; the limitations
of PPE.
• Auctions must establish log-in procedures for staff and customers and maintain that
information for potential contact notification.
Requirements for Automobile Racing Tracks

In addition to the Healthy at Work Minimum Requirements, automobile racing
tracks must meet the requirements below in order to reopen and remain open:

• Racetracks must permit only authorized employees and essential drivers and crews on
the premises. This includes, but is not limited to, racetrack employees, race teams (e.g.,
drivers, pit crews, and other support staff), emergency medical personnel, and necessary
suppliers and vendors (e.g., gasoline suppliers).
• Racetracks must ensure that everyone on premises adhere to social distancing guidelines
by staying at least six (6) feet away from other people whenever possible. Controls must
be established and maintained when six (6) feet of physical distancing is not feasible.
• Racetracks must prohibit fans and outside media.
• Racetracks must ensure that employees, drivers or their crews may not bring guests,
including family members.
• Racetracks must ensure, to the greatest extent practicable, that drivers and their crews
on the racetrack premises remain in their assigned pre- and post-trackside space, except
when going to and from the track, bathrooms, or dining facilities for the purpose of food
carry-out or pick-up.
• Racetracks must, to the greatest extent practicable, stagger normal procedures (e.g., race
vehicle shipping/arrival and employee entry/exit) to ensure that employees do not
congregate. Racetracks should ensure that employees and other persons present abide
by appropriate social distancing requirements.
• Racetracks must ensure racetrack kitchens or other food facilities on premises follow
social distancing while in the kitchen, to the greatest extent practicable, and provide food
only via-carry out or curbside pick-up.

• Racetracks must ensure that adequate supplies of soap and/or sanitizer are readily
multiple, easily accessible sanitation locations. Refer to CDC guidelines for best
sanitization practices.
• Racetracks must ensure cleaning and sanitation of frequently touched equipment, tools,
objects, and surfaces with appropriate disinfectants. This may include, but is not limited
to: vehicle/equipment door handles; keys; gear shifts; steering wheel/operator controls
and levers; fuel pump dispensers; door knobs; light switches; phones;
computers/keyboards; copiers; elevator buttons; toilets; faucets; sinks; countertops;
paper towel dispensers; desktops; handrails; folders; vending machines; counters; tables;
and cabinets and knobs. Appropriate disinfectants include EPA registered household
disinfectants, diluted household bleach solution, and alcohol solutions containing at least
60% alcohol.
• Racetracks must ensure, to greatest extent practicable, that facilities and work areas are
sanitized and disinfected after persons suspected or confirmed to have COVID-19 have
• Racetracks must, to the greatest extent practicable, discourage employees and racing
crews from sharing tools or equipment. Shared tools and equipment must be disinfected
between uses.
Personal Protective Equipment (PPE)

Requirements
• Racetracks must ensure employees, racing crews and others (e.g. emergency medical
crews and suppliers) use appropriate face coverings and other personal protective
equipment (PPE). No sharing of PPE is permissible. Racetracks should ensure employees
and racing crews wear appropriate face coverings at all times practicable. For employees
that are isolated in closed offices or assigned areas with more than six (6) feet of social
distancing, face coverings are not necessary at all times. However, when an employee
may come within six feet of other people, a face covering must be worn. If not required
by OSHA for a job task, N95 / KN95 masks shall not be provided to non-healthcare sector
workers as face coverings. Cloth masks shall be used instead.

• Racetracks must educate and train all individuals including employees, temporary
Racetracks must communicate with employees any industry, company, and/or site
• Racetracks must appoint a Safety Coordinator to manage and maintain compliance of

the Healthy at Work requirements.
• Racetracks must provide special accommodations for persons at higher risk for severe
• Racetracks must require sick workers or race team members to stay at home or go home
if they start to have symptoms. Racetracks must have COVID-19 testing information
readily available for employees and race team members, including testing location
information.
Requirements for Aquatic Centers and Businesses

In addition to the Healthy at Work Minimum Requirements, aquatic
centers must meet the requirements below in order to reopen and remain open:
Social Distancing Requirements for Aquatic Centers

• These requirements allow aquatic centers to reopen for lap swimming, walking,
practices, or exercise that can achieve the following social distancing measures. This
includes swim lessons and lifeguard training with groups of 10 or fewer students.
General leisure and entertainment swimming pool activities are prohibited. Pools
without swim lanes must remain closed.
• Aquatics centers must limit the number of visitors present at their facility to a maximum
of 33% of occupancy, not including employees. The facility or business should develop an
organized scheduling system to minimize interactions between visitors and allows
employees to sanitize commonly touched surfaces between visitors. There should be no
open swim opportunities. Swimming sessions should be scheduled by appointment over
the phone or online.
• Aquatics centers should provide services and conduct business via phone or Internet to
the greatest extent practicable. Any employees who are currently able to perform their
job duties via telework (e.g., accounting staff) should continue to telework.
• Aquatic centers should eliminate the use of any waiting areas, provide services by
appointment only and communicate by phone or text when the visitor may enter the
facility. These facilities or businesses must ensure visitors do not congregate in or around
the premises before, during or after their visit.
• Aquatic centers should, to the greatest extent practicable, modify traffic flow to minimize
contacts between employees and visitors.
• Aquatic centers should ensure employees use digital files rather than paper formats (e.g.,
• Aquatic centers should communicate with clients and receive payments through
contactless payment options (e.g., phone or Internet), to the greatest extent practicable.
For those facilities or businesses that cannot use contactless payments, the facility or
business should install floor or wall decals for cashier queuing areas to demark safe
waiting distances of a six (6) feet minimums.
• If the swim lanes are six (6) feet wide or wider, swimmers may swim one per lane, leaving
from opposite ends and separated by lane lines during their entire swim. For example, a
six-lane pool would have odd lanes enter at one end and even lanes enter at the opposite
end. Swimmers are not permitted to stop and/or interact at the same end as an adjacent
lane. If the swim lanes are less than six (6) feet wide, then swimmers must swim in every
other lane, with one empty lane separating each swimmer.
• Swim coaches may be on site, but must maintain a physical distance of at least six (6) feet
from their students, other coaches, other swimmers and spectators at all times.
• Swimmers may have one member of their household present to observe and must
maintain a physical distance of at least six (6) feet from coaches, other swimmers or other
observers. Observers may not congregate in groups with other observers while at the
aquatics or swimming facility or business.
• Aquatic centers should prohibit gatherings or meetings of employees of ten (10) or more
during work hours, permit employees to take breaks and lunch outside, in their office or
personal workspace, or in such other areas where proper social distancing is attainable.
• Aquatic centers should discourage employees from sharing phones, desks, workstations,
handhelds/wearables, or other work tools and equipment to the greatest extent
practicable.
Cleaning and Disinfecting Requirements for Aquatic Centers
• Aquatic centers should ensure that their facilities, including locker rooms, common areas,
breakrooms and restrooms are properly cleaned and ventilated.
• Aquatic centers should provide hand sanitizer, handwashing facilities, tissues and waste
baskets in convenient locations to the greatest extent practicable.
• Aquatic centers must encourage visitors to properly wash their hands when they arrive at
the facility. If visitors refuse to properly wash their hands, the facility or business may
refuse access to the facility.
• Aquatic centers should establish a policy as to whether to serve clients who do not adhere
to the business’s policy on requiring adherence to CDC guidelines.
• Aquatic centers making restrooms or locker rooms available must ensure restrooms
frequently touched surfaces are appropriately disinfected after each use (e.g., door knobs
and handles). Swimmers may shower at the facility only if the facility or business can
routinely adequately clean and sanitize the showers and locker rooms between visitors.
• Aquatic centers should ensure disinfecting wipes or other disinfectant are available at
shared equipment. Swimmers should not share towels or equipment that has not been
properly disinfected.
• Aquatic centers must ensure cleaning and sanitation of frequently touched surfaces with
appropriate disinfectants. Areas with frequently touched surfaces include fitting rooms,
doors, PIN pads, and common areas. Appropriate disinfectants include EPA registered

containing at least 60% alcohol.
• Aquatic centers must establish a cleaning and disinfecting process that follows CDC
guidelines when any individual is identified, suspected, or confirmed COVID-19 case.
• Aquatic centers should ensure employees do not use cleaning procedures that could re-
aerosolize infectious particles. This includes, but is not limited to, avoiding practices such
as dry sweeping or use of high-pressure streams of air, water, or cleaning chemicals.
• Aquatic centers should disallow visitors from any direct use of retail items or products
prior to sale.
• Aquatic centers should encourage visitors to touch only those retail items or products
they intend to buy.
• Aquatic centers should ensure any retail items or products that are touched by visitors
but not purchased are set aside and appropriately cleaned prior to returning to sales
shelves. Businesses should refer to CDC cleaning guidelines for guidance.
• Aquatic centers must ensure appropriate face coverings and other personal protective
equipment (PPE) are used by employees so long as such use does not jeopardize the
employees’ health or safety.
• Aquatic centers must ensure their employees wear face masks for any interactions
between visitors and co-workers or while in common travel areas of the business (e.g.,
aisles, hallways, stock rooms, breakrooms, bathrooms, entries and exits). Employees are
not required to wear face masks while alone in personal offices or if doing so would pose
a serious threat to their health or safety.
• Aquatic centers should ensure all visitors wear face masks while in the facility. Swimmers
should wear a face mask until they are entering the pool, and should wear the mask after
exiting the pool. Aquatic centers should make masks available for visitors, however
visitors may bring and use their own face mask. If visitors, suppliers or vendors refuse to
wear masks, the facility or business may refuse those individuals entrance to the facility.
• Aquatic centers should establish a policy as to whether to serve visitors who do not adhere
to the business’s policy to adhere to CDC guidelines.
• Aquatic centers must ensure employees use gloves, along with any PPE normally used for
routine job tasks, when cleaning equipment, workspaces, and high-touch areas of the
business.
• Aquatic centers must ensure gloves are available to employees engaging in high-touch
• Aquatic centers must ensure employees wear gloves while handling products during
• Aquatics and swimming facilities and business must train employees to properly dispose
of or disinfect PPE, inspect PPE for damage, maintain PPE, and the limitations of PPE.
• Aquatic centers must train employees to use PPE. This training includes: when to use PPE;
what PPE is necessary; and how to properly put on, use, and remove PPE.
• Aquatic centers must place conspicuous signage at entrances and throughout the store
alerting staff and customers to the required occupancy limits, six feet of physical distance,
and policy on face coverings and face masks. Signage should inform employees and
clients about good hygiene and new practices.
• Aquatic centers should, to the greatest extent practicable, implement hours where
service can be safely provided to clients at higher risk for severe illness per CDC guidelines.
These guidelines are available at: https://www.cdc.gov/coronavirus/2019-
• Aquatic centers should ensure employees are informed that they may identify and
Requirements for Bowling Alleys

In addition to the Healthy at Work Minimum Requirements, bowling alleys must
• Bowling alleys must limit the number of clients present in any given facility to 33% of the
occupational capacity of the facility. Employees are excluded from this 33% maximum.
• Bowling alleys must provide services and conduct business via phone or Internet to the
greatest extent practicable. Any employees who are currently able to perform their job
duties via telework (e.g., accounting staff) should continue to telework.
• Bowling alleys must eliminate the use of any waiting areas, provide lane reservations by
appointment only and instruct patrons to arrive at their appointed time only. Bowling alleys
must ensure patrons do not congregate in the lobby or entrance before or after their
appointment.
• Bowling alleys must limit party size to ten (10) people or fewer. Persons not living within
the same household should not be permitted bowl on the same lane or in an adjacent lane.
• Bowling alleys must establish controls to ensure one (1) lane of separation between
parties/groups.
• Bowling alleys must ensure employees use digital files rather than paper formats (e.g.,
• Bowling alleys must establish controls to ensure six (6) feet of physical distancing and
safeguards to reduce the opportunity to spread the virus. This includes, for example,
installation of portable or permanent non-porous physical barriers (e.g., plexiglass shields)
at rental or check-out counters and between employee work stations.
• Bowling alleys must communicate with clients and receive payments through contactless
payment options (e.g., phone or Internet) to the greatest extent practicable. For those
bowling alleys that cannot utilize contactless payments, the business should install floor or
wall decals for cashier queuing areas to demark safe waiting distances of a six (6) feet
minimums.
• Bowling alleys must ensure that everyone on premises adhere to social distancing
guidelines by staying at least six (6) feet away from other people whenever possible.
• Bowling alleys should, to the greatest extent practicable, modify traffic flow to minimize
contacts between employees and patrons.
• Bowling alleys must ensure, to the greatest extent practicable, visitors remain in their
assigned space (e.g. bowling lane and associated seating area), except when going to and
from the lane to shoe rental areas, bathrooms, or dining facilities.
• Bowling alleys must close in-person bar service to avoid congregating. However, drinks
may be purchased by ordering from wait staff and delivery or to-go service.
• Bowling alleys with restaurants must adhere to the Healthy at Work Restaurant Guidance.
• Bowling alleys with snack and refreshment bars must ensure employees use proper social
distancing while preparing and serving food to the greatest extent practicable.
• Bowling alleys must, to the greatest extent practicable, stagger normal procedures (e.g.,
employee shift schedules, shipping/arrival and visitor entry/exit) to ensure that people
do not congregate.

• Bowling alleys must ensure that adequate supplies of soap and/or sanitizer are readily
multiple, easily accessible sanitation locations, including at all lanes assigned to
customers. Refer to CDC guidelines for best sanitization practices.
• Bowling alleys must ensure cleaning and sanitation of frequently touched equipment,
tools, objects, and surfaces with appropriate disinfectants. This may include, but is not
limited to: bowling balls; bowling shoes; lane surfaces such as the ball rack, air fans and
score keeping surfaces; equipment door handles; operator controls and levers; door
knobs; light switches; phones; computers/keyboards; copiers; elevator buttons; toilets;
faucets; sinks; countertops; paper towel dispensers; desktops; handrails; folders; vending
machines; counters; tables; and cabinets and knobs. Appropriate disinfectants include
solutions containing at least 60% alcohol.
• Bowling alleys must ensure, to greatest extent practicable, that facilities and work areas
are sanitized and disinfected after persons suspected or confirmed to have COVID-19 have
• Bowling alleys must, to the greatest extent practicable, discourage patrons from sharing
bowling balls.

Requirements
• Bowling alleys must ensure employees, patrons and other visitors (e.g. suppliers and
vendors) use appropriate face coverings and other personal protective equipment (PPE).
No sharing of PPE is permissible. If not required by OSHA for a job task, N95 / KN95 masks
shall not be provided to non-healthcare sector workers as face coverings. Cloth masks
must be used instead.
• Bowling alleys must ensure appropriate face coverings and other personal protective
equipment (PPE) is used by employees so long as such use does not jeopardize the
employees’ health or safety.
• Bowling alleys must ensure their employees wear face masks for any interactions between
clients and co-workers or while in common travel areas of the business (e.g., aisles,
hallways, stock rooms, breakrooms, bathrooms, entries and exits). Employees are not
required to wear face masks while alone in personal offices or if doing so would pose a
serious threat to their health or safety.
• Bowling alleys must ensure appropriate face coverings and other personal protective
equipment (PPE) is used by employees whenever they are within six feet of other
employees or customers so long as such use does not jeopardize the employees’ health
or safety. Bowling alleys should make masks available for patrons; however, patrons may
bring and use their own face masks if they wish. If patrons, suppliers or vendors refuse to
wear masks, the bowling alley may refuse those individuals entrance to the facility.
• Bowling alleys must establish a policy as to whether to serve patrons who do not adhere
to the business’s policy on requiring masks.
• Bowling alleys must ensure employees use gloves, along with any PPE normally used for
routine job tasks, when cleaning equipment, workspaces, and high-touch areas of the
business.
• Bowling alleys must ensure gloves are available to employees engaging in high-touch
• Bowling alleys must ensure employees wear gloves while handling products during

• Bowling alleys must educate and train all individuals including employees, temporary
• Bowling alleys must communicate with employees any industry, company, and/or facility
• Bowling alleys must appoint a Safety Coordinator to manage and maintain compliance of
the Healthy at Work requirements.
• Bowling alleys must provide special accommodations for persons at higher risk for severe
• Bowling alleys must require sick workers or patrons members to stay at home or go home
if they start to have symptoms.
• Bowling alleys must have COVID-19 testing information readily available for employees
and patrons, including testing location information.
Requirements for Fishing Tournaments

In addition to the Healthy at Work Minimum Requirements, fishing tournaments

• Public and Private Fishing Tournaments Background:
o Fishing tournaments can vary widely in size from small 5-10 boat tournaments to the
rare, much larger 100 or more boat tournaments. However, the majority are small
tournaments that typically draw no spectator crowds and are comprised of mostly
participants.
o In a typical fishing tournament, participants are gathered for a brief pre-meeting either
the night before the tournament or the morning of. Many of the small tournaments
have no pre-meeting. The morning of the tournament participants launch boats
independently and wait to fish until start time. Larger tournaments will have staggered
start times. From that point on participants are out on the water with two to a boat at
most. Boater registration data indicates that the most common type of boat is 16-21
feet long, providing adequate room to social distance.
o At the end of the tournament they arrive and weigh-in fish prior to announcing the
winners. On larger tournaments, return times are also staggered.
o In a normal tournament the only times participants are likely to aggregate and not be
able to social distance is during the pre-meeting and weigh-ins. Despite the crowded
“look” of a full boat ramp parking lot, all participants are out on the water and
separated for the duration of the event. Since they are all bringing their own boats and
vehicles, there is no shared equipment that is in need of disinfecting. For them to re-
open, tournament organizers must mitigate the potential crowding at the registration as
well as the weigh-ins, which should not be difficult.
o Since tournaments vary so widely in format, organizers should follow and refer to the
Healthy at Work General Minimum Requirements which can be found on the Healthy at
Work website – https://healthyatwork.ky.gov.
• Public and Private Fishing Tournaments must follow the following social distancing
guidance:
o Tournament organizers shall not hold in-person pre-tournament meetings (e.g.,

organizational and competitor registration/sign ups), these meetings can be done
via conference call or online forum.
o When tournaments are larger than 10 boats, they must, to the greatest extent
practicable, stagger launch times or use multiple launch ramps.
o Tournament participants must stay in vehicles or boats during launching process

and give adequate space for others launching.
o Weigh-ins must be conducted outdoors.
o All participants must stay with their vehicle or boat until going up to weigh in.
o Tournament organizers should encourage participants to wear neck gaiters or

face masks when coming up to weigh-in.
o Only one participant may weigh in a time, weigh in tanks must be staggered at
least six feet apart.
o No crowds may gather to observe weigh-ins. Specifically, fishing tournament

organizers must follow the Healthy at Work Guidance for Gatherings of Up to Ten
(10) People for any portion of their event where a group may congregate.
o Prize money, trophies or other acknowledgement of placement can be issued by

mail or via electronic means.

• Fishing tournament organizers should develop and implement a plan and procedures to
ensure any frequently touched surfaces are properly cleaned and ventilated routinely.
Appropriate disinfectants include EPA registered household disinfectants, diluted
household bleach solution, and alcohol solutions containing at least 60% alcohol.
Facilities and businesses must establish a cleaning and disinfecting process that follows
CDC guidelines when any individual is identified, suspected, or confirmed COVID-19 case.
• Fishing tournament organizers should encourage organizers, patrons or anyone

associated with the tournament to frequently wash their hands or use hand sanitizer.
• Fishing tournament organizers should ensure disinfecting wipes or other disinfectant are
available at shared equipment.
• Fishing tournament organizers should ensure organizers and patrons do not use cleaning
procedures that could re-aerosolize infectious particles. This includes, but is not limited
to, avoiding practices such as dry sweeping or use of high-pressure streams of air, water,
or cleaning chemicals.
• Fishing tournament organizers must ensure appropriate face coverings and other personal
protective equipment (PPE) is used by organizers, staff and patrons when they are in close
proximity to others so long as such use does not jeopardize the individuals health or safety.
• Fishing tournament organizers must establish policy as to whether to allow patrons to

participate in the tournament who do not adhere to the tournament’s policy on requiring
masks.
• Fishing tournament organizers must train any applicable staff how to properly use PPE,
how to properly dispose of or disinfect PPE, inspect PPE for damage, maintain PPE, and
the limitations of PPE.
• Fishing tournament organizers must ensure organizers or any applicable staff use gloves,
along with any PPE normally used for routine job tasks, when cleaning equipment and
high-touch areas of the tournament.
• Fishing tournament organizers must ensure cloth face masks and gloves are available to
organizers and staff engaging in high-touch activity to the greatest extent practicable
provided that they do not create additional hazards while being worn.
• Fishing tournament organizers must place conspicuous signage alerting staff and patrons
of the required six (6) feet of social distancing of physical distance, and the tournament’s
policy on face coverings. Signage should inform organizers, staff and patrons about good
hygiene and new practices.
• Fishing tournament organizers should, to the greatest extent practicable, discourage

those staff and patrons who are at higher risk for severe illness from participating if they
cannot participate safely per CDC guidelines. These guidelines are available
at:https://www.cdc.gov/coronavirus/2019-ncov/faq.html#Higher-Risk
• Fishing tournament organizers should ensure that organizers, staff and patrons are
concerns in order to reduce potential risk of exposure at the tournament. All signage,
education and training must be communicated in the language best understood by the
individual receiving the education and training.
Requirements for Movie theaters

In addition to the Healthy at Work Minimum Requirements, movie theaters must
• Movie theaters must limit the number of patrons present to 33% of the occupational
capacity of the facility. Employees are excluded from this 33% maximum.
• Movie theaters should conduct business via phone or Internet to the greatest extent
practicable. Any employees who are currently able to perform their job duties via telework
(e.g., accounting staff) should continue to telework.
• Movie theaters must minimize the use of any waiting areas, sell tickets online and instruct
patrons to arrive at the start time on their pre-purchased ticket. For those movie theaters
that cannot utilize online ticketing, the business should install floor or wall decals for
cashier queuing areas to demark safe waiting distances of a six (6) feet minimums. Ticketing
employees should be shielded by glass or plexiglass and utilize appropriate PPE.
• Movie theaters must scan electronic or bar coded tickets in a way that protects the patron
and employees. For example, a patron may scan the ticket while being observed by a movie
theater employee who is shielded by plexiglass or tickets may be scanned by an employee
wearing appropriate PPE and shielded by a glass or plexiglass barrier. If the movie theater
cannot implement the suggestions above or does not use barcoded tickets, the theater
must implement another method of taking tickets that does not involve close personal
contact. Movie theaters must ensure patrons do not congregate in the theater before or
after their movie.
• Movie theaters should ensure employees use digital files rather than paper formats (e.g.,
• Movie theaters must establish controls to ensure six (6) feet of physical distancing and
safeguards to reduce the opportunity to spread the virus. This includes, for example,
installation of portable or permanent non-porous physical barriers (e.g., plexiglass shields)
at snack bar counters and between employee work stations.
• Movie theaters must ensure that everyone on premises adhere to social distancing
guidelines by staying at least six (6) feet away from others not in their household whenever
possible.
• Movie theaters must assign theater seats, to the greatest extent practicable, in order to
arrange appropriate social distance theater seating (e.g. staggering open seats, closing
every other aisle or closing sets of seats to keep groups who live in the same household
socially distant from other groups or individuals).
• Movie theaters should, to the greatest extent practicable, modify traffic flow to minimize
contacts between employees and patrons.
• Movie theaters must ensure, to the greatest extent practicable, patrons remain in their
assigned space (e.g. bowling lane and associated seating area), except when going to and
from their seat to a snack bar, bathrooms, or dining facilities.
• Movie theaters with bars or restaurants, not including snack bars, must adhere to the
Healthy at Work Restaurant Guidance.
• Movie theaters with snack bars must ensure employees utilize proper social distancing
while preparing and serving food, to the greatest extent practicable.
• Movie theaters must, to the greatest extent practicable, stagger normal procedures (e.g.,
employee shift schedules, shipping/arrival and visitor entry/exit) to ensure that people
do not congregate.

• Movie theaters must ensure that adequate supplies of soap and/or sanitizer are readily
available to employees and patrons and that they promote frequent hand washing by
setting up multiple, easily accessible sanitation locations. Refer to CDC guidelines for best
sanitization practices.
• Movie theaters must ensure cleaning and sanitation of frequently touched equipment,
tools, objects, and surfaces with appropriate disinfectants. This may include, but is not
limited to: theater chairs; hand rails; door handles; operator controls and levers; door
knobs; light switches; phones; computers/keyboards; copiers; elevator buttons; toilets;
faucets; sinks; countertops; paper towel dispensers; desktops; handrails; folders; vending
machines; counters; tables; and cabinets and knobs. Appropriate disinfectants include
solutions containing at least 60% alcohol.
• Movie theaters must ensure, to greatest extent practicable, that facilities and work areas
are sanitized and disinfected after persons suspected or confirmed to have COVID-19 have

Requirements
• Movie theaters must ensure their employees, suppliers, and vendors wear cloth face
coverings or face masks for any interactions between clients and co-workers or while in
common travel areas of the business (e.g., aisles, hallways, stock rooms, breakrooms,
bathrooms, entries and exits). Employees are not required to wear face masks while alone
in personal offices, when more than six (6) feet away from anyone else, or if doing so
would pose a serious threat to their health or safety.
• Movie theaters should establish a policy as to whether to serve patrons who do not
adhere to the business’s policy on requiring masks. Movie theaters should make masks
available for patrons; however, patrons may bring and use their own face masks if they
wish. If patrons refuse to wear masks, the theater may refuse those individuals entrance
to the facility.
• Movie theaters must ensure employees use regularly-replaced gloves, along with any PPE
normally used for routine job tasks, when cleaning equipment, workspaces, and high-
touch areas of the business.
• Movie theaters must ensure gloves are available to employees engaging in high-touch
• Movie theaters must ensure employees wear gloves while handling products during

• Movie theaters must educate and train all individuals including employees, temporary
• Movie theaters must communicate with employees any industry, company, and/or facility
employee information is posted such as bulletin boards.
• Movie theaters must appoint a Safety Coordinator to manage and maintain compliance
of the Healthy at Work requirements.
• Movie theaters must provide special accommodations for persons at higher risk for severe
• Movie theaters must require sick workers to stay at home or go home if they start to have
symptoms. Theaters may also refuse entry to patrons displaying COVID-19 symptoms.
• Movie theaters must have COVID-19 testing information readily available for employees
and patrons, including testing location information.
• Movie theaters must post the Healthy At Work General Guidance poster at the entrances
to the theater as well as any other place where the reminders are useful (e.g., snack bars,
bathrooms and individual theater doors/entry ways).
Requirements for Childcare Programs1

In addition to the Healthy at Work Minimum Requirements, childcare programs
Timeline For Reopening Childcare Programs
JUNE 8, 2020
o In-home childcare programs (Type 2, Certified, and Registered Providers) may

reopen subject to the requirements below; Limited Duration Childcare programs
will remain open.
JUNE 15, 2020
o Center-based licensed childcare programs and day camps may reopen to all
patrons subject to the requirements below.
Regulatory Requirements for Childcare Programs
• Since childcare programs were only required to pause their services, the Division of
Regulated Childcare will operate as if all programs are reopening on the dates listed
above. If a program chooses to postpone opening or permanently close, the program will
need to immediately contact the Division of Regulated Childcare to update their status.
• When childcare programs reopen, they will not need to redo background checks for all
previously employed staff members due to the rapback feature on KARES. They will need
to update the KARES background check database for any employees that have left the
programs’ employment during the closure.
• The childcare programs will also need to contact the ECE-TRIS database and remove
employees from the database that have left the programs’ employment during the
closure.
• If there is a new childcare program director when the program reopens, director change
paperwork will need to be filed with the Division of Regulated Childcare immediately.
1
Childcare programs includes summer day camps for children.
Social Distancing Requirements for Childcare Programs

• All childcare programs will need to utilize a maximum group size of ten children per group.
Registered and certified providers will still need to implement their lower maximum
group sizes listed in regulations.
• The square footage requirement of space per child is still required, so a center cannot
place ten children in a classroom if the Division of Regulated Childcare has approved the
room for a smaller number of children.
• Ratios for children under the age of twenty-four months will still be in place, so those
classrooms will need to have two adults present if caring for the maximum classroom size
of ten children.
• Children will remain in the same group of ten children all day without being combined
with another classroom.
• Those approved to be in a childcare program are limited to:

o Facility staff
o Persons with legal authority to enter (first responders, Department for
Community Based Services, Division of Regulated Childcare, etc.).
o Necessary utility workers
o Professionals providing medical/therapeutic services for children with special
needs
o Children enrolled in the facility
o Parents or legal guardians of children enrolled in the program
o In family childcare homes, the family members who live in the home of the
approved childcare provider may also be in the childcare program.
• Childcare programs many not provide access to visitors or students conducting classroom
observations.
• The same staff members should work with the same children each day in order to reduce
additional exposure, including the staff members that give breaks to primary staff
members.
• With families’ permissions (if children are in the videos), childcare programs may use
video/virtual observations for practicum students and virtual tours for perspective
families.
• Childcare programs shall stagger playground time between classroom groups.
• Childcare programs will not hold center-wide family events.
• Childcare programs will not hold field trips.

• Childcare programs will use a centralized drop-off and pick-up location to eliminate
unnecessary traffic to classrooms and exposure of children. Childcare programs must, to
the greatest extent practicable, conduct pick-up and drop-off each day in a manner that
ensures social distancing. Childcare staff members should operate child pick-up and drop-
off by class.
• Childcare programs should, if practicable, demarcate spots on the ground spread at six
(6) foot intervals immediately outside the facility where parents and custodial adults may
safely wait to pick-up children. Childcare programs should encourage parents and
custodial adults to wear cloth face coverings or masks during pick-up and drop-off.
• Childcare programs should, to the greatest extent practicable, encourage staff members
to conduct group activities that can be performed while observing social distancing (e.g.
coloring/painting) and limiting sharing of toys/items.
• Childcare programs must establish a pick-up and drop-off procedure and schedule to
ensure that children are entering and leaving one at a time.
• Childcare programs are encouraged to provide outdoor instructions for children of

appropriate age. Childcare programs holding outdoor fitness classes must follow the
Healthy at Work Guidelines for Groups of 10 People or Fewer for those classes.
• Childcare programs must eliminate “lost and found” bins.
• Childcare programs should discontinue use of water fountains to the greatest extent
practicable. Childcare programs should encourage customers to bring their own water
bottles.
• Childcare programs must eliminate use of high-contact sports/team sports areas (e.g.
basketball courts, football fields, and soccer fields) until such time as
requirements/guidance are issued for those activities.
• Childcare programs contained within any other business that has reopened must follow
the Minimum Requirements and specific requirements for that business. These are
available at Healthy at Work.
• Childcare programs should provide services and conduct business via phone or Internet
to the greatest extent practicable. Any employees who are currently able to perform their
job duties via telework (e.g., accounting staff) should continue to telework.
• Childcare programs should, to the greatest extent practicable, modify traffic flow to
minimize contacts between employees and children.
• Childcare programs should ensure employees use digital files rather than paper formats
(e.g., documentation, invoices, inspections, forms, agendas) to the greatest extent
practicable.
• Childcare programs should communicate with parents and custodial adults and receive
payments through contactless payment options (e.g., phone or Internet), to the greatest
extent practicable. For those programs that cannot use contactless payments, the
program should demark safe waiting distances of six (6) feet minimums in cashier queuing
areas.
• Childcare programs must discourage employees from sharing phones, desks,

workstations, handhelds/wearables, or other work tools and equipment to the greatest
extent practicable.
• Childcare programs must ensure that controls are established to ensure social distancing
in locker rooms, including disabling lockers to enforce six (6) feet of social distancing.
Childcare programs should discourage use of locker rooms.
• Childcare programs must ensure limited use of restroom programs at any one time based
on the facility size and current social distancing guidelines.
Cleaning and Disinfecting Requirements for Childcare Programs

• Each childcare program will create and post a cleaning and sanitizing plan specific to the
individual childcare program and describe how additional cleaning and sanitizing will be
implemented in the childcare program. Toys that cannot be cleaned and sanitized should
not be used.
• Toys that children have placed in their mouths or that are otherwise contaminated by
bodily secretions should be set aside until they are cleaned by hand by a person wearing
gloves.
• Machine washable cloth toys should not be used at this time.
• Group of infants or toddlers cannot use shared toys unless they are washed and sanitized
before being moved from one group to the other.
• Childcare programs must set aside toys that need to be cleaned by putting them separate
container marked for soiled toys until they can be cleaned.
• Children’s books, like other paper-based materials, are not considered a high risk for
transmission and do not need additional cleaning or disinfection procedures. Plastic
infant and toddler books may be cleaned and sanitized as the material allows.
• Use bedding (sheets, pillows, blankets, sleeping bags) that can be washed. Keep each
child’s bedding separate, and consider storing in individually labeled bins, cubbies, or
bags. Bedding that touches a child’s skin should be cleaned weekly or before any use by
another child.
• Classrooms will not utilize family style dining. Staff will prepare plates and pass them out
to the individual children.
• No transportation will be offered at childcare programs while the public school system is
closed. When the public school system resumes classes, childcare programs will model
the transportation policies of the Kentucky Department of Education.
• Childcare programs must ensure that their programs, including locker rooms, common
areas, breakrooms and restrooms are properly cleaned and ventilated.
• Childcare programs must ensure that staff members/employees and children practice
hand hygiene frequently. For example, staff members and children should wash or
sanitize their hands in the following circumstances: upon arrival for the day, after breaks,
upon returning from outside, after toileting or assisting a child with toileting, after each
diaper change or pull-up change, after contact with bodily fluids or cleaning up spills or
objects contaminated with bodily fluids, after cleaning or sanitizing or using any chemical
products, after handling pets, pet cages or other pet objects that have come in contact
with the pet, before eating, serving or preparing food or bottles or feeding a child, before
and after completing a medical procedure or administering medication, when visibly
soiled (must use soap and water), and prior to departure. This may require facility staff to
assist children with hand hygiene.
• Childcare programs must encourage staff members/employees and children to limit

touching their mouth, nose, and face.
• Childcare programs must provide hand sanitizer (as appropriate), handwashing programs,
tissues and waste baskets in convenient locations to the greatest extent practicable.
• Childcare programs making restrooms or locker rooms available must ensure frequently
touched surfaces are regularly disinfected (e.g., door knobs and handles).
• Childcare programs must ensure cleaning and sanitation of frequently touched surfaces
with appropriate disinfectants, in accordance with appropriate Kentucky childcare
standards.
• Childcare programs must establish a cleaning and disinfecting process that follows CDC
guidelines to address when any individual is identified, suspected, or confirmed as a
COVID-19 case.
• Childcare programs must ensure employees do not use cleaning procedures that could
re-aerosolize infectious particles. This includes, but is not limited to, avoiding practices
such as dry sweeping or use of high-pressure streams of air, water, or cleaning chemicals.
Screening and Illness Requirements
• Children and adults will be screened for fever and contagious symptoms upon entry into
the childcare program consistent with the Minimum Requirements.
• Childcare program staff members who demonstrate symptoms of COVID-19 must be

tested for the illness.
• Children or adults that test positive for COVID-19 must follow the recommendations of
their local health department on when to return to the childcare program.
• When a child shows a fever or other contagious symptoms, the child must be removed
from the classroom immediately and placed in a safe, secluded area. The parent or
guardian must remove the child from the childcare program within one hour.
• Childcare programs must notify enrolled families and staff of a diagnosed case of COVID19
in the program, while still protecting the privacy of the diagnosed individual.

• Adults must wear a face mask while inside a childcare program (in-home or center-based)
unless doing so would represent a serious risk to their health or safety or they are more
than 6 feet away from any other individual.
• Children who are five (5) years of age or under should not wear masks due to increased
risks of suffocation and strangulation. Childcare programs may recommend to the
parents of children over five (5) that their child wear a mask and provide information
about the benefits of masking.
• Childcare providers should wear gloves while serving food and preparing bottles. Gloves
should be changed between bottle feedings.
• Childcare programs should make masks available for parents and custodial adults where
in-facility interaction is necessary. Parents and custodial adults may bring and use their
own face mask. If parents or custodial adults, suppliers, or vendors refuse to wear masks,
the facility may refuse those individuals entrance to the facility.
• Childcare programs should establish a policy as to whether to allow parents or custodial

adults enter the facility if the parent or custodial adult refuses to adhere to the facility’s
policy to adhere to CDC guidelines.
• Childcare programs must ensure employees use gloves, along with any PPE normally used
for routine job tasks, when cleaning equipment, toys, playspaces, workspaces, and high-
touch areas of the facility.
• Childcare programs must ensure gloves are available to employees engaging in high-touch
• Childcare programs must ensure employees wear gloves while handling products during
drop-off and pick-up as well as during any shipping and receiving.
• Childcare programs must have required cleaning supplies and PPE (masks, latex/non-latex
gloves) on site before they can reopen their facility. Childcare Aware staff will screen
programs to make sure that supplies are on site prior to opening.
• All staff members will need to take a refresher training on cleaning and sanitizing
procedures, as well as mandatory reporting of child abuse before the date that their
program reopens. Limited Duration Childcare staff members will need to complete their
training before their program transitions back to a licensed or certified program.
• Centers will not be penalized if staff members did not complete required training hours
during the childcare closure. Childcare programs will begin annual training hours again
on July 1, 2020, and they will have until June 30, 2021 for providers to complete their
annual required training hours.
• Additional monitoring will be conducted to verify compliance with the additional

preventative measures required due to the pandemic. The Division of Regulated
Childcare will conduct monitoring for enhanced health and safety requirements along
with required annual inspections. Childcare Aware coaches will assist with preventative
monitoring by assisting centers prior to their reopening date to make sure they are
prepared to open for children. Childcare Aware coaches and Childcare Health Consultants
will assist centers with implementing new preventative requirements once the centers
are open.
• Annual visits from the Division of Regulated Childcare will begin soon after childcare
programs reopen.
• All childcare providers with a completed and approved KARES background check are ready
to return to the classroom and safely be left alone with children.
• Since the statewide fingerprint background check system has not yet reopened, new
childcare providers will have to file name-based background checks prior to starting in
the center. They will not be left alone with children until the named-based background
checks are sent back to the childcare facility with an approved status. Once the fingerprint
background system reopens, the employees will go and complete the fingerprint system
once time and staffing at the DCBS regional offices will allow for them to receive an
appointment.
• Childcare programs must train staff/employees to use PPE. This training includes: when
to use PPE; what PPE is necessary; and how to properly put on, use, and remove PPE.
• Childcare programs must establish log-in procedures and maintain that information for
potential contact notification
• Childcare programs should ensure employees are informed that they may identify and
Requirements for Horse Shows

In addition to the Healthy at Work Minimum Requirements, horse shows
Social Distancing Requirements for Horse Shows

• Horse shows must ensure that the number of people on horse show grounds or in a ring does
not exceed the number that can safely socially distance at six (6) feet or more away from one
another - this may result in a smaller amount of competitors that would normally be allowed.
• Horse shows must ensure that stalls, if used, are large enough to permit six (6) feet of social
distancing between exhibitors; if not, every other stall must be used.
• Horse shows must ensure that horse trailers are parked a minimum of six (6) feet apart to the
• Horse shows must arrange judges’ and other officials’ spaces to ensure that they can maintain
six (6) feet of social distance from others.
• Horse shows must limit attendance to: essential staff, volunteers, and service providers; judges;
trainers; participants/riders; groomers, and; owners. If a participant is a minor, their parents or
primary caregivers may attend with them.
• Horse shows must not permit the public, spectators, fans, family members (other than
parents/caregivers of a minor), or outside media on competition grounds.
• Horse shows must use online registration, check-in, and payment to the greatest extent
practicable.
• Horse shows must configure any competition offices or check-in spaces to ensure that
both staff and competitors can remain six (6) feet apart to the greatest extent practicable.
Horse shows should consider markings showing six (6) feet of distance as well as plexiglass
or other physical, non-porous barriers in these spaces.
• Horse shows must stagger horse arrival, check-in, entry, exit, and horse departure times
to avoid participants, staff, and volunteers congregating.
Temperature and Health Screening Requirements for Horse Shows
• Horse shows must require temperature and health screenings for all volunteers, officials,
competition staff, service providers, and participants consistent with the Temperature and
Health Screening Guidance in the Healthy At Work Minimum Requirements. These screenings
may either be self-administered at home or administered on-site prior to entry.
Cleaning and Disinfecting Requirements for Horse Shows
• Horse shows must ensure that their facilities, including stalls, locker rooms, common
areas, breakrooms and restrooms are properly cleaned and ventilated. Horse shows are
encouraged to open exterior doors and windows to increase ventilation.
• Horse shows should provide hand sanitizer, handwashing facilities, tissues and waste
• Horse shows must limit the use of shared equipment (e.g., tack, grooming supplies, lead
shanks) to the greatest extent practicable. If equipment must be shared, horse shows
must sanitize that equipment between each use.
• Horse shows making restrooms or locker rooms available must ensure frequently touched
surfaces are frequently cleaned and disinfected (e.g., door knobs and handles).

• Horse shows must require a facemask or face covering for all staff, officials, volunteers,
service providers and participants when not mounted on a horse. Horse shows do not
have to require participants on horseback to wear a mask, but the horse shows should
permit them to do so if they wish. Horse shows must not disqualify or penalize a
participant for wearing a facemask or face covering while competing.
• Horse shows should ensure that gloves are worn by any essential staff or volunteers when
handling shared show equipment and that those gloves are replaced after each use.
Training and Safety Requirements for Horse Shows
• Horse shows must train essential staff to use PPE. This training includes: when to use PPE;
what PPE is necessary; how to properly put on, use, and remove PPE; how to properly
dispose of or disinfect PPE; how to inspect PPE for damage; how to maintain PPE, and;
the limitations of PPE.
• Horse shows must establish log-in procedures for essential staff and participants and
maintain that information for potential contact notification.
Requirements for Educational & Cultural Opportunities and

Attractions
In addition to the Healthy at Work Minimum Requirements, educational and
cultural opportunities and attractions facilities and businesses must meet the
requirements below in order to reopen and remain open:
• Educational and cultural opportunities and attractions facilities and businesses include,
but are not limited to, the following:
o Aquariums, distilleries (including tours), libraries, limited outdoor attractions

(e.g., cave tours, zoos other than petting zoos, and the Salato Wildlife Education
Center), public and private museums and historic sites (e.g., the Kentucky Derby
Museum, Speed Museum and the Kentucky History Center), and wineries. 1

• All facilities and businesses that operate restaurants or snack bars as a component of their
facility or business must follow the Healthy at Work Requirements for Restaurants.
• All facilities and businesses that operate retail stores as a component of their facility or
businesses must follow the Healthy at Work Requirements for Retail Businesses.
• All facilities and businesses must minimize the use of any waiting areas. Facilties and
businesses must make reservations and sell tickets over the phone or online to the
greatest extent practicable. For those facilities that cannot use online
reservations/ticketing/sales, the facility should install floor or wall decals for cashier
queuing areas to demark safe waiting distances of a six (6) feet minimums. Ticketing
employees should be shielded by glass or plexiglass and use appropriate personal
protective equipment.
• Outdoor facilities and businesses must limit the persons, not including employees,
present in any given tourism facility or business to an amount small enough to permit at
least six (6) feet of social distancing between all individuals or households. Additionally,
tourism facilities and businesses must follow the Healthy at Work Guidance for
Gatherings of Up To Ten (10) People.
1
Amusement parks (e.g., Kentucky Kingdom), music venues, waterparks, fairs, festivals, sports complexes
and other convention or entertainment venues that attract large crowds are not included in this guidance
and shall remain closed until additional guidance and dates are announced.
• Outdoor facilities and businesses must promote safe and healthy experiences by
following the Healthy At Work minimum requirements, to the greatest extent
practicable.
• Outdoor facilities must develop and implement a plan and protocols to create
transmission barriers, where possible, and promote and enforce social distancing;
implement touchless solutions, where practical; and enhance and promote sanitation
and hygiene practices.
• Indoor facilities and businesses must limit the persons, not including employees,
present
in any given tourism oriented facility or business to 33% of the capacity of the
facility. Additionally, tourism oriented facilities and businesses must follow the
Healthy at Work Guidance for Gatherings of Up To Ten (10) People.
o Additional guidance:
 Facilities with exterior exhibits: promote and enforce social distancing and
masking when patrons and staff are in close proximity or passing by one
another; ensure patrons do not touch exhibits; and develop one-way traffic
touring routes/patterns, to the extent practicable.
 Facilities with interior passive, self-guided tours: promote and enforce

social distancing and masking when patrons and staff are in close
proximity or passing by one another; ensure patrons do not touch
exhibits; develop one-way traffic touring routes/patterns, to the extent
practicable; and demarcate social distancing signage to avoid
congregation between groups of patrons.
 Facilities with interior guided tours: promote and enforce social

distancing and masking when patrons and staff are in close proximity or
passing by one another; ensure patrons do not touch exhibits; develop one-
way traffic touring routes/patterns, to the extent practicable;
demarcate social distancing signage to avoid congregation between
groups of patrons; and ensure staff guides strictly follow social distancing
protocols and wear face masks at all times, unless they are more than six
(6) feet away from anyone else or doing so would put their health or
safety at risk.

• Facilities and businesses should develop and implement a plan and procedures to ensure
the facility, including offices and workstations, are properly cleaned and ventilated
routinely.
• Facilities and businesses should encourage employees and patrons or customers to

frequently wash their hands or use hand sanitizer, which should be provided by the
employer.
• Facilities and businesses must ensure cleaning and sanitation of frequently touched
surfaces (e.g., door knobs or handles and counter tops) with appropriate disinfectants.
Appropriate disinfectants include EPA registered household disinfectants, diluted
household bleach solution, and alcohol solutions containing at least 60% alcohol.
Facilities and businesses must establish a cleaning and disinfecting process that follows
CDC guidelines when any individual is identified, suspected, or confirmed COVID-19 case.
• Facilities and businesses should ensure employees wipe their workstations/cash registers
down with disinfectant at the end of their shift or at any time they discontinue use of
their workstations/cash register for a significant period of time.
• Facilities and businesses should ensure disinfecting wipes or other disinfectant are
available at shared equipment.
• Facilities and businesses should ensure employees do not use cleaning procedures that
chemicals.
• Facilities and businesses must ensure appropriate face coverings and other personal
protective equipment (PPE) is used by employees whenever the employees are within six
(6) feet of anyone else, so long as such use does not jeopardize the employees’ health or
safety. Facilities and businesses must train employees to use PPE. This training includes:
when to use PPE; what PPE is necessary; and how to properly put on, use, and remove PPE.
• Facilities and businesses must require contractors and vendors to wear face coverings or
masks while at the facility.
• Facilities and businesses may, if they wish, require patrons and customers to wear masks
while inside or within six (6) feet of anyone outside of their household. Facilities and
businesses who do so should establish a policy as to whether to serve customers who do
not adhere to the business’s policy on requiring masks. Facilities and businesses may
choose not to serve those customers who refuse to wear a mask in order to protect their
employees and other customers.
• Facilities and business must train employees to properly dispose of or disinfect PPE,
inspect PPE for damage, maintain PPE, and the limitations of PPE.
• Facilities and businesses must ensure employees use gloves, along with any PPE normally
used for routine job tasks, when cleaning equipment, workspaces, and high-touch areas
of the business.
• Facilities and businesses must ensure gloves are available to employees engaging in high-
touch activity to the greatest extent practicable provided that they do not create
additional hazards while being worn.
• Facilities and businesses must ensure employees wear gloves while handling products
during shipping and receiving.
• Facilities and businesses must place conspicuous signage at entrances and throughout the
facility alerting staff and patrons or customers to the required occupancy limits, six feet
of physical distance, and policy on face coverings. Signage should inform employees and
patrons or customers about good hygiene and new practices.
• Facilities and businesses should, to the greatest extent practicable, implement hours
where service can be safely provided to constituents at higher risk for severe illness per
CDC guidelines. These guidelines are available at:
https://www.cdc.gov/coronavirus/2019-ncov/faq.html#Higher-Risk
• Facilities and businesses should ensure employees are informed that they may identify
and communicate potential improvements and/or concerns in order to reduce potential
risk of exposure at the workplace. All education and training must be communicated in
the language best understood by the individual receiving the education and training.
VERSION 1.0– Effective June 15, 2020
Guidance for Youth Sports and Athletic Activities

Timeline For Reopening Youth Sports
JUNE 15, 2020
• Low touch, outdoor youth sports and athletic activities (e.g.,

track and field, biking, tennis, golf, horseback riding, and
cross-country, and baseball/softball/teeball) may resume
practices without competition. Practices should consist of ten
(10) youths or fewer, with no more than one (1) adult coach per
group, while following the Healthy at Work social distancing
Guidelines for Groups of 10 People or Fewer. Multiple groups
may practice but must adhere to the social distancing guidelines
in the next section. Any individual not essential for the conduct
of these practices should not attend.
• Low touch, indoor youth sports and athletic activities (e.g.

gymnastics, swimming, diving, bowling, solo-dance/solo-ballet,
tap-dance, and archery) may resume small group practices and
workouts without competition. Practices and workouts should
consist of ten (10) youths or fewer, with no more than one (1)
adult coach per group, while following the Healthy at Work social
distancing Guidelines for Groups of 10 People or Fewer. Practices
are limited to socially distanced, no touch1, low sharing2 skills
training, unless necessary to protect the health or safety of a
youth participant. Multiple groups may practice but must adhere
to the social distancing guidelines in the next section. Any
individual not essential for the conduct of these practices should
not attend.
• High touch, indoor youth sports and athletic activities (e.g.

karate/martial arts, basketball, cheerleading, tandem or team
dance, ice hockey, volleyball, fencing, wrestling) may hold small
group physical fitness workouts, exercises, and skills training of
ten (10) youths or fewer, with no more than one (1) adult coach
1
“No touch” means no physical contact between youth athletes is permitted. All individuals must avoid physical contact
with others including high fives, huddles, or other close contact occurring before, during, or after activities unless the
contact is for the purpose of safety. Scrimmages and games are not permitted. “Low touch” means only minimal,
necessary contact between youth athletes is permitted.
2
“Low sharing” means minimal, necessary sharing of youth sports and athletic activity equipment between youth
athletes (e.g. limiting shared items to groups of ten (10) or fewer). “Medium sharing” means moderate levels of sharing
of youth sports and athletic activity equipment between youth athletes (e.g. limiting shared items to groups of fifty (50)
or fewer). Shared equipment must be sanitized between uses to the greatest extent practicable.
per group, while following the Healthy at Work social distancing

Guidelines for Groups of 10 People or Fewer. No competition is
permitted Skills training must be socially distanced no touch, and
low sharing, unless necessary to protect the health or safety of a
youth participant. Multiple groups may conduct small group
physical fitness workouts, exercises, and skills training but must
groups must adhere to the social distancing guidelines in the next
section. Any individual not essential for the conduct of these
practices should not attend.
• High touch, outdoor youth sports and athletic activities (e.g.

football, soccer, lacrosse, flag football, field hockey) may resume
small group physical fitness workouts, exercises of (10) youths or
fewer, with no more than one (1) adult coach per group, while
following the Healthy at Work social distancing Guidelines for
Groups of 10 People or Fewer. No competition is permitted. Skills
training must be socially distanced, no touch, and low sharing,
unless necessary to protect the health or safety of a youth
participant. Multiple groups may hold small group physical
fitness workouts and exercises, but groups must adhere to the
social distancing guidelines in the next section. Any individual not
essential for the conduct of these practices should not attend.
JUNE 29, 2020
• Low touch, outdoor youth sports and athletic activities may

resume competition with up to fifty (50) spectators following the
Healthy at Work social distancing Guidelines for Groups of 50
People or Fewer. Competitions, practices, and other activities
must adhere to the social distancing guidelines in the next
section.
• Low touch, indoor youth sports and athletic activities may

resume competition with up to fifty (50) spectators, following the
People or Fewer. Competitions, practices, and other activities
section.
• High touch, indoor youth sports and athletic activities may

resume team/group practices without competition. Youth
participants should be subdivided small groups of ten (10) youths
or fewer, with no more than one (1) adult coach per group, while
following the Healthy at Work social distancing Guidelines for
Groups of 10 People or Fewer. All team/group practices are
limited to fifty (50) youths or fewer, in accordance with the
People or Fewer. Practices are limited to low touch, medium
sharing activities, unless necessary to protect the health or safety

of a youth participant. Multiple groups may practice but must
adhere to the social distancing guidelines in the next section.
• High touch, outdoor youth sports and athletic activities may

resume team/group practices without competition. Youth
participants should be in subdivided small groups of ten (10)
youths or fewer, with no more than one (1) adult coach per
group, while following the Healthy at Work social distancing
Guidelines for Groups of 10 People or Fewer. All team/group
practices are limited to fifty (50) youths or fewer, in accordance
with the Healthy at Work social distancing Guidelines for Groups
of 50 People or Fewer. Practices are limited to low touch,
medium sharing activities, unless necessary to protect the health
or safety of a youth participant. Multiple groups may practice but
section.
Pursuant to KRS 156.070 and 702 KAR 7:065, common and private school facilities will receive
additional compliance guidelines, restrictions and allowances from the Kentucky Department of
Education through its designee, the Kentucky High School Athletic Association, including
requirements for facility use by school and non-school teams.

League officials, coaches, and other responsible adults should do the following:
• Establish procedures to ensure youth athletes are socially distanced to the greatest extent
practicable at all times. League officials, coaches, and other responsible adults should
emphasize physical and cardiovascular fitness and individual skill building activities and
limit group/team activities. League officials, coaches, and other responsible adults
developing activities and practices should consider that older youth might be better able
to follow directions for social distancing and take other protective actions.
• Modify workouts, exercise, skills training, practices, competitions to increase distance

between athletes, coaches, officials, and spectators, to the greatest extent practicable.
During rest periods or other periods of inactivity social distancing should be increased and
congregating eliminated.
• Space youth athletes at least six (6) feet apart on the field while participating in the
youth sport or athletic activity during warmup, skill building activities, and simulation
drills.
• Ensure that during team/group practices, physical fitness workouts, exercises, or skills
training where youth athletes are subdivided small groups, that each small groups
remains together and separated from other groups to the greatest extent practicable. For
example, groups should work through stations, rather than switching groups or mixing
groups.
• Discourage unnecessary physical contact, such as high fives, handshakes, fist bumps, or
hugs. To encourage sportsmanship league officials, coaches, and other responsible
adults should encourage alternative, socially distanced, signs of mutual respect. (e.g. tip
the cap, wave, salute, bow).
• Eliminate, to the greatest extent practicable, touching of shared equipment and gear
(e.g., protective gear, balls, bats, racquets, mats, or water bottles). Where practicable,
league officials, coaches, and other responsible adults should provide individual, non-
shared equipment to youth athletes. Where not practicable, league officials, coaches, and
other responsible adults should encourage youth athletes to provide their own
equipment and water bottles.
• Ensure that youth athletes in high-touch sports and activities only play “full contact”
during game/competition situations.
• Encourage parents and custodial adults to monitor their own child (e.g. younger children
could sit with parents or caregivers).
• Minimize the level of contact between youth athletes who may be at higher risk for severe
illness, such as children who may have asthma, diabetes, or other health problems.
https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-at-higher-
risk.html.League officials, coaches, and other responsible adults are encouraged to offer
virtual coaching and in-home drills for youth athletes at a higher risk for severe illness.
• Limit any nonessential visitors, spectators, volunteers, and activities involving external
groups or organizations.
• Decrease team sizes to the greatest extent practicable..
• Eliminate travel competitions or scrimmages outside of the local community (e.g.,

neighborhood, town, or community).
• Educate staff and youth athlete families about when they should stay home and when
they can return to activity.
• Direct coaches, staff, families, and youth athletes to stay home and/or seek medical
attention if they have tested positive for or are showing symptoms of COVID-19.
• Prohibit individuals, including coaches, players, and families, who have recently had
a close contact with a person with COVID-19, from participating in youth sports and
athletic activities.
• Identify staff to help maintain social distancing among youth athletes, coaches,
umpires/referees, and spectators.
• Prohibit sick coaches, staff members, umpires/officials, or youth athletes from returning
until they have met CDC’s criteria to discontinue home isolation
https://www.cdc.gov/coronavirus/2019-ncov/hcp/disposition-in-home-patients.html.
• Prioritize outdoor, as opposed to indoor, practice and play as much as possible.
• Create distance between youth athletes when explaining drills, rules, or other instruction.
• Emphasize physical and cardiovascular fitness individual skill work and drills to the
• Direct youth athletes to wait in their cars with their parent or other custodial adult until
just before the beginning of a practice, warm-up, game, or other activity.
• Eliminate the use of carpools or van pools. When riding in an automobile to a sports event,
encourage youth athletes to ride to the sports event with persons living in their same
household.
• Stagger arrival and drop-off times or locations by group or put in place other protocols
to limit contact between groups and with parents, custodial adults, and spectators as
much as possible. For example, league officials, coaches, and other responsible adults
should increase the amount of time between practices and competitions to allow for
one group to depart before another group enters the facility.
• Limit youth sports participation to staff and youth who live in the local geographic area
(e.g., community, city, town, or county) to reduce risk of spread from areas with higher
levels of COVID-19.
• Stage, to the greatest extent practicable, intra-squad scrimmages instead of playing

games with other teams to minimize exposure among players and teams.
• Limit any nonessential visitors, spectators, volunteers, and activities involving external
groups or organizations as much as possible – especially with individuals not from the
local geographic area (e.g., community, town, city, or county).
• Designate a youth sports program staff person to be responsible for responding to COVID-
19 concerns. All coaches, staff, officials, and families should know who this person is and
how to contact them.
• Establish protocols for notifying staff, officials, families, and the public of youth sports
facility closures and restrictions in place to limit COVID-19 exposure (e.g., limited hours
of operation).
• Implement flexible sick leave policies and practices for coaches, officials, and staff
that enable employees to stay home when they are sick, have been exposed, or caring for
someone who is sick.
• Develop policies for return-to-play after COVID-19 illness.
• Virtually train coaches, officials, and staff on all safety protocols.

• Prohibit congregating of youth athletes, spectators, families, coaches, officials, and other
persons prior to or following practices or athletic events.
• Maintain a complete list of coaches, youth athletes, and league officials present at each
event to include the date, beginning and ending time of the event, plus, name, address,
and phone contact to be made available upon request from local health department
• Ensure team meetings occur virtually or over the phone.
• Alert the local health department of the event prior to competitive tournaments.

• prohibit spitting or eating of seeds, gum, or similar products.
• Share these requirements with all youth athletes, coaches, spectators, officials, and
employees prior to the beginning of the program.
Facilities holding youth sports and athletic activities, as well as league officials, coaches, and other
responsible adults should do the following:
• Provide physical guides, such as signs and tape on floors or playing fields, to make sure
that coaches and youth athletes remain at least 6 feet apart.
• Establish flexible worksites (e.g., telework), flexible work hours (e.g., staggered shifts),
and policies for social distancing between employees, staff, and others
• Stagger the use of lockers, and clean and disinfect locker rooms between uses.
• Install touchless sensors on sinks and hand dryers to the greatest extent practicable.
• Install digital check-in and registrations as well as touch-free entries and exits to the
• Eliminate “lost and found” bins, vending stations, saunas, steam rooms, water coolers,
water fountains, and vending stations to the greatest extent practicable.
• Ensure that controls are established to ensure social distancing in locker rooms,
including disabling lockers to enforce six (6) feet of social distancing. Facilities holding
youth sports and athletic activities should discourage use of locker rooms or consider
measures to socially distance youth athletes (e.g. closing every other locker or groups of
lockers in order to space out usage) and sanitize frequently.
• Dugouts or other areas where social distancing is not possible should not be used.
• Create and post a cleaning and sanitizing plan specific to the youth sport or athletic
activity, describing how additional cleaning and sanitizing will be implemented.
• Sanitize equipment and used items before, during, and after every event. If equipment
cannot be sanitized during the activity, only participants of a single team/group must use
equipment and items related to the activity and opposing participants or group members
must avoid touching that equipment.
• Set aside touched or shared equipment that requires sanitation and encourage youth
athletes to keep their individual equipment separate from the equipment of other
athletes.
• Ensure that their programs, including locker rooms, common areas, breakrooms and
restrooms are properly cleaned and ventilated.
• Ensure that staff members/employees and youth athletes practice hand hygiene
frequently. For younger youth athletes assistance may be required.
• Provide hand sanitizer (as appropriate), handwashing programs, tissues and waste
• Establish a cleaning and disinfecting process that follows CDC guidelines to address when
any individual is identified, suspected, or confirmed as a COVID-19 case.
• Ensure employees do not use cleaning procedures that could re-aerosolize infectious
particles. This includes, but is not limited to, avoiding practices such as dry sweeping or
use of high-pressure streams of air, water, or cleaning chemicals.
• Clean and disinfect frequently touched surfaces on the field, court, or play surface (e.g.,
drinking fountains) at least daily, or between uses as much as possible. Use of shared
objects and equipment (e.g., balls, bats, gymnastics equipment) should be limited, or
cleaned between use by each individual if possible.
• Ensure there are adequate supplies of shared items to minimize sharing of equipment to
the extent possible (e.g., protective gear, balls, bats, water bottles); otherwise, limit use
of supplies and equipment to one group of youth athletes at a time and clean and
disinfect between use.
• Ensure that, if food is offered at any event, meals be pre-packaged boxes or bags for each
attendee instead of a buffet or family-style meal. Avoid sharing food and utensils. Offer
hand sanitizer or encourage hand washing.
• Ensure ventilation systems or fans operate properly. Increase circulation of outdoor air
as much as possible, for example by opening windows and doors. Do not open windows
and doors doing so poses a safety or health risk (e.g., risk of falling or triggering asthma
symptoms) to players or others using the facility.
• Support healthy hygiene by providing supplies including soap, paper towels, tissues, and
no-touch/foot pedal trash cans. If hand washing facilities are not available, provide hand
sanitizer with at least 60% alcohol (for coaches, staff and older players who can safely use
hand sanitizer).
• Should close off areas used by a sick person and do not use these areas until after cleaning
and disinfecting them (for outdoor areas, this includes surfaces or shared objects in the
area, if applicable).
• Should wait at least 24 hours before cleaning and disinfecting. If 24 hours is not feasible,
wait as long as possible.
Screening and Illness Requirements
League officials, coaches, and other responsible adults should
• Conduct daily health checks (e.g., symptom checking) of coaches, officials, staff, and
youth athletes safely and respectfully to the greatest extent practicable.
• Use examples of approved screening methods found in CDC’s supplemental Guidance for
Child Care Programs that Remain Open as a guide for screening children, and CDC’s
General Business FAQs for screening staff.
• Staff members who demonstrate symptoms of COVID-19 must be tested for the illness.
• Should direct coaches, staff, families, and youth athletes that test positive for COVID-19
to follow the recommendations of their local health department on when to return to the
youth sport or activity.
• Ensure that when a youth athlete shows a fever or other contagious symptoms, the youth
athlete is moved to a in a safe, secluded area until the youth athlete’s parent or custodial
adult can pick-up the youth athlete.
• Notify all league families and youth athletes of a diagnosed case of COVID19 in the
program, while still protecting the privacy of the diagnosed individual.
• Encourage coaches, staff, umpires/officials, and families of youth athletes to self-report

to the youth sports organization if they have symptoms of COVID-19, a positive test for
COVID-19, or were exposed to someone with COVID-19 within the last 14 days.
• Wear face coverings at all times, unless doing so would represent a serious risk to their
health or safety.
• Ensure youth athletes wear cloth face coverings or masks when not actively participating
in the youth sport or athletic activity, unless doing so would represent a serious risk to
their health or safety. Youth athletes who are five (5) years of age or under should not
wear masks due to increased risks of suffocation and strangulation.
• Recommend to the parents of children over five (5) that their child wear a mask and
provide information about the benefits of masking.
• Establish a policy as to whether to allow parents, custodial adults, or other spectators

attend youth sports competitions or events if the individual refuses to wear a face
covering or comply with social distancing guidelines.
• Ensure gloves are available to staff members, coaches, volunteers engaging in high-touch
• Ensure, to the greatest extent practicable, that cloth face coverings or masks be worn by
coaches, youth sports staff, officials, parents, and spectators as much as possible.
• Provide youth athletes and their families information on proper use, removal, and
washing of cloth face coverings.
• Establish a policy as to whether youth athletes, who do not adhere to these guidelines or
its own policy on requiring masks, will be allowed to participate in that youth sport or
athletic activity. League officials, coaches, and other responsible adults may choose not
to allow a youth athlete to participate if the athlete refuses to wear a mask of comply
with social distancing guidelines.
• Ensure that staff, volunteers, coaches, youth athletes are trained how to properly clean
cloth face coverings and masks.
• Ensure that staff, volunteers, coaches use gloves when cleaning equipment, facilities, or
other items requiring sanitation.

Facilities holding youth sports and athletic activities (e.g. competitions, recitals,
tournaments, practices, games) should do the following:
• Place conspicuous signage at entrances and throughout the facility alerting youth athletes
and spectators of the guidelines for the facility and the event. Signage should inform
youth athletes and spectators about good hygiene and new practices.
• Establish procedures for disinfecting high-touch surfaces (seating, locker rooms, etc.).
• Post signage at entrance that no one with a fever or symptoms of COVID-19 may enter
the facility.
• Implement, to the greatest extent practicable, reserved seating for spectators at higher risk
for severe illness per CDC guidelines.
• Ensure employees are informed that they may identify and communicate potential
improvements and/or concerns in order to reduce potential risk of exposure at the
workplace. All education and training should be communicated in the language best
understood by the individual receiving the education and training.
• Broadcast regular announcements on public announcement system, encouraging COVID-

19 prevention and new policies and behaviors that prevent spread of COVID-19.
• Establish scheduling policies to ensure additional time is available to clean and disinfect
between uses, where a facility is shared.
• Ensure parents, custodial adults, youth athletes, and spectators are informed that they
may identify and communicate potential improvements and concerns in order to reduce
the risk of exposure at the workplace. All education and training should be communicated
in the language best understood by the individual receiving the training.
• Place emphasis on progressive training where general conditioning is emphasized first,

followed by strength and body conditioning and then moving on to anything sports
specific.
Other Requirements
• Facilities holding youth sports and athletic events that contain:
aquatic centers must follow the Healthy at Work Requirements for Aquatic Centers.
fitness centers or other weight lifting and strength building equipment must follow the
Healthy at Work Requirements for Fitness Centers.
bowling alleys must follow the Healthy at Work Requirements for Bowling Alleys.
horse tracks/arenas must follow the Healthy at Work Requirements for Horse Shows
and/or Healthy at Work Requirements for Racetracks as applicable.
dining areas, snack bars, concession stands must follow the Healthy at Work
Requirements for Restaurants.

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Case: 3:20-cv-00036-GFVT Doc #: 43 Filed: 06/15/20 Page: 1 of 100 - Page ID#: 447

TONY RAMSEK, et al., PLAINTIFFS,

ANDREW BESHEAR, et al., DEFENDANTS.

LEE ANN GOFF

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