The COVID-19 pandemic has had downstream effects on global elections as governments are forced to balance health and safety concerns of the public against the need for maintaining a democratic process. To optimize the chance of a safe election from a public health perspective, all citizens must play a role in reducing community transmission.

Before Election Day

A low community transmission rate on election day will minimize the chance of exposure and infection in voters, poll workers, and election officials. Local public health departments are promoting this objective through three strategies: behavior modification, disease surveillance, and outbreak control.¹

Behavior modification guidelines target preventing disease transmission and include recommendations for individuals and organizations. These include isolation and quarantine of people who have symptoms of COVID-19, vigilant surface cleaning, hand hygiene, respiratory etiquette (covering coughs or sneezes), masking while in public or when interacting with people outside of one’s immediate household, and maintaining physical distancing of six feet or greater with others.

Disease surveillance requires a robust testing program with adequate supply of materials, efficient laboratory test turnaround times, and delivery of results to patients and health care workers. Stratification of data by demographic factors including age, race/ethnicity, and neighborhood will help communities respond to rises in disease transmission rates. Public health departments should partner with a variety of community stakeholders to promote active engagement in testing efforts.

In Arlington, Virginia , people line up and look at sample ballots during first day of early voting, 2020 presidential election.
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When a case is identified through testing, successful outbreak control requires case investigation and contact tracing (CI/CT). Although time-intensive, effective CI/CT programs have been shown to reduce the reproductive rate of the virus (the R) from local values of more than 2.0 to 0.4 by offering two key interventions.² First, a case investigator should educate an infected individual on how to self-isolate for up to 14 days to decrease transmission to others. Successful isolation may require referrals to social services such as isolation and quarantine hotels, food delivery programs, or temporary income assistance. The second important step, contact tracing, involves determining who else in a patient’s household, workplace, and community may have been a “close contact” (a person who was exposed to the person for greater than 15 minutes). Close contacts are contacted by the department of public health and are confidentially advised of an exposure; assessed for symptoms; and advised for quarantine, self-monitoring, or testing, depending on the time since exposure and symptoms.³

Role of Emergency Physicians

Emergency physicians can play a role in helping patients stay healthy and vote safely this November through both clinical care and communication. Most directly, our duty as frontline physicians involves ensuring that members of higher-risk groups (eg, older individuals, immunocompromised individuals, residents of group living facilities, and essential workers) are appropriately tested leading up to and following the election. This includes excellent history-taking around symptoms and potential exposures as well as identifying close contacts so cases can be identified early and spread of disease is mitigated.

Beyond history and workup, communication is crucial. According to a large, nationally representative survey released in April 2020, trust in hospitals and physicians during COVID-19 is high, particularly relative to other institutions and groups.⁴ We are important sources of information and education regarding public health guidelines such as hand hygiene, face masks, and social/physical distancing. We can help patients understand what to expect if they undergo testing and link to appropriate resources so they can safely isolate.

As various state and local elections officials adapt their voting strategies this year, we can inform our patients about their local voting options. Not only are these discussions clinically relevant, they have legal and logistical precedent. The 1993 National Voter Registration Act allows any institution providing “public assistance,” including hospitals, to participate in nonpartisan voter registration and information sharing.⁵ National organizations such as VotER and Community Health Vote empower thousands of health care workers to engage patients in conversations about voter registration and safe voting plans.^6–8

How to Have Safe In-Person Voting

Healthy and safe elections are a priority for all Americans and our democracy. Clear, nonpartisan, and evidence-based recommendations are needed for public health and elections officials to follow as they develop policies and procedures in advance of election day.⁹

Early and mail-in voting can help reduce crowd volumes, reduce in-person contact, and ultimately reduce transmission risk. Some individuals will need to vote in person, and for these people, a uniform, evidence-based public health message about what to expect at polling sites is important. This messaging should include using hand hygiene, maintaining physical distance of at least six feet between individuals, and wearing face masks that cover the nose and mouth to prevent the transmission of COVID-19. For safe in-person elections to occur, elections officials should increase the number of polling locations to avoid overcrowding and relocate polling locations to large, well-ventilated areas to allow for appropriate physical distancing. Localities should aim to have polling locations in large, well-ventilated sites such as sports arenas, concert venues, convention centers, school gymnasiums, or community recreation centers. For optimal infection control, voting locations should conduct check-in activities outdoors (weather permitting), establish separate points of entry and exit for voters, and have unidirectional flow of foot traffic. Additionally, ventilation should be optimized by avoiding recirculation of potentially contaminated air.

Polling locations should have adequate supplies to support healthy hygiene for voters, poll workers, and elections officials. This includes hand sanitizer with at least 60 percent alcohol, soap, paper towels, no-touch trash cans, disinfectant wipes, and face masks. Polling sites should be thoroughly cleaned with an Environmental Protection Agency–approved disinfectant prior to opening on election day, with special attention given to high-touch surfaces, such as poll worker stations and voting booths. These areas and any reusable items should be routinely disinfected throughout the day. Hand sanitizer should be available at entrances, exits, and each step of the voting process for voters and poll workers. Polling locations should have plexiglass barriers between workers and voters at registration tables.

In addition, voters should expect to arrive at polling locations early and expect to wait. They can minimize their time and risk of COVID-19 by filling out a sample ballot prior to election day to make in-person voting time-efficient, vote during an off-peak time, and come alone to the polling location.

Election day does not happen without poll workers, and wide-scale campaigns to recruit extra workers may reduce the burden of individual exposures to others. Poll workers should be trained in the appropriate use of personal protective equipment and offered free testing for COVID-19 before and after their shifts at the polls. Any individual concerned about their personal risk for COVID-19 as a poll worker should consult their physician.

COVID-19 is the greatest social, health, and economic threat of our generation. As we approach Nov. 3, it is critical that local communities, health care workers, and public health departments work together to minimize the risk of COVID-19. We have the knowledge and scientific evidence to have a safe election. Now is the time to implement policies and practices and keep our patients informed about them. No person should have to choose between the right to vote and the right to be healthy.

Disclosure: Dr. Kuppalli is a consultant for GalaxoSmithKline.

References

1. Considerations for election polling locations and voters: interim guidance to prevent spread of coronavirus disease 2019 (COVID-19). Centers for Disease Control and Prevention website. Available at: https://www.cdc.gov/coronavirus/2019-ncov/community/election-polling-locations.html. Accessed Sept. 28, 2020.
2. Sun K, Viboud C. Impact of contact tracing on SARS-CoV-2 transmission. Lancet. 2020;20(8):876-877.
3. Beidas RS, Buttenheim AM, Feuerstein-Simon R, et al. Optimizing and implementing contact tracing through behavioral economics: contact tracing is not just about making phone calls. NEJM Catalyst website. Available at: https://catalyst.nejm.org/doi/full/10.1056/CAT.20.0317. Accessed Sept. 28, 2020.
4. Lazer D, Baum MA, Ognyanova K, et al. The state of the nation: a 50-state COVID-19 survey. Katya Ognyanova website. Available at: http://www.kateto.net/COVID19%20CONSORTIUM%20REPORT%20April%202020.pdf. Accessed Sept. 28, 2020.
5. H.R. 2–National Voter Registration Act. Congress website. Available at: https://www.congress.gov/bill/103rd-congress/house-bill/2/text. Accessed Sept. 28, 2020.
6. Health Center Tool Kit. Community Health Vote website. Available at: http://communityhealthvote.net/toolkit/. Accessed Sept. 28, 2020.
7. VotER website. Available at: https://vot-er.org. Accessed Sept. 28, 2020.
8. Stockman F. In era of sickness, doctors prescribe unusual cure: voting. The New York Times website. Available at: https://www.nytimes.com/2020/07/25/us/in-era-of-sickness-doctors-prescribe-unusual-cure-voting.html. Accessed Sept. 28, 2020.
9. Brennan Center for Justice, The Infectious Diseases Society of America. Guidelines for healthy in-person voting. Brennan Center for Justice website. Available at: https://www.brennancenter.org/our-work/research-reports/guidelines-healthy-person-voting. Accessed Sept. 28, 2020.

Dr. Kuppalli (left)is a physician in the division of infectious diseases at the Medical University of South Carolina in Charleston. Dr. Grade (middle) and Dr. Mercer (right) are physicians in the department of emergency medicine at the University of California, San Francisco.