Rapid Scoping Review of Evidence of Outdoor Transmission of COVID-19

The COVID-19 pandemic is both a global health crisis, and a civic emergency for national governments, including the UK. As countries across the world loosen their lockdown restrictions, the assumption is generally made that the risk of COVID-19 transmission is lower outdoors, and this assumption has shaped decisions about what activities can recommence, the circumstances in which they should re-commence, and the conditions under which they should re-commence. This is important for events and activities that generate outdoor gatherings of people, including both participatory and spectator sport events, protests, concerts, carnivals, festivals, and other celebrations. The review, which was designed to be undertaken rapidly in 15 days, returned 14 sources of evidence of outdoor transmission of COVID-19, and a further 21 sources that were used to set the context and understand the caveats that should be considered in interpreting the review findings. The review found very few examples of outdoor transmission of COVID-19 in everyday life among c. 25,000 cases considered, suggesting a very low risk. However risk of outdoor transmission increases when the natural social distancing of everyday life is breached, and gathering density, circulation and size increases, particularly for an extended duration. There was also evidence that weather had a behavioural effect on transmission, with temperatures that encourage outdoor activity associated with lower COVID-19 transmission. Due to lack of surveillance and tracing systems, and confounding factors and variables, there was no evidence that robustly tested transmission at outdoor mass gatherings (circa 10,000+ people), which are as likely to generate transmission from the activities they prompt (e.g. communal travel and congregation in bars) as from outdoor transmission at the gathering itself. The goal of hosts and organisers of events and activities that generate outdoor gatherings of people is to prevent the escalation of risk from sporadic transmission to the risk of transmission through a cluster outbreak. Considerations for such hosts and organisers include: (1) does the gathering prompt other behaviours that might increase transmission risk?; (2) for each part of the event or activity, how dense is the gathering, how much do people circulate, how large is the gathering, and how long are people there?; (3) is rapid contact tracing possible in the event of an outbreak? These considerations should take place relevant to the size of the underlying risk, which includes the rate of infection in the community and the likely attendance of vulnerable groups. Risk must be balanced and mitigated across the risk factors of density, circulation, size and duration. No one risk factor presents an inherently larger risk than any other, but neither is any one risk factor a magic bullet to eliminate risk. Finally, it is clear that the largest risks from gatherings come from spontaneous or informal unregulated and unmitigated events or activities which do not consider any of the issues, risks and risk factors outlined in this paper