The coordination committee of the convocation tasked the Nodal Officer (COVID-19 outbreak preparedness) to prepare a prevention protocol for the 14^th March gathering at our institute. WHO had already declared COVID-19 a pandemic on 11^th March. All aspects of preparation for the event were in place, with the involvement of students and parents from all over the country. As cancellation was not an option, the protocol was prepared.

The communication and coordinating mechanisms were well-incorporated in the blueprint. A protocol was made by the committee with members being nodal officers, the central coordinators for the entire convocation, and the clinical team including resident doctors, public health specialists, and nursing officers. The logistics and equipment required were laid down in the protocol.

The convocation ceremony was held in temporary tents, made on an aluminum hanger structure, erected specially for the purpose. Four major tents or gathering areas were constructed. The main tent which also contained a stage had seating for 1500 persons and covered 20,000 ft² area. The tent had five entry points. This tent had a high ceiling and was well-ventilated: tower air-conditioning was provided for the stage area. Two more tents were erected for dining purposes: the main dining area of 12,450 ft² and a small area of 2100 ft², to accommodate about specific 100 guests. This area also had ventilation on two sides along with air conditioning. Lastly, there was another tent of 2500 ft² for the kitchen area where all the cooking for the event was done. This was also open on three sides. Arrangements were made for toilet facilities with portable toilets and changing rooms in the nearby building of the nursing college.

Clear cut understanding of the risks and the description of the mass gathering including the type of the gathering, the level of audience involvement, the level of knowledge about the disease, the likely immunity of the age group of the attendees to potential infections, the ventilation at the venue, and the accommodation sites were ascertained.

The convocation was a university graduation ceremony to award degrees to students and honorary graduates. In this gathering, the main attendees were the students who were being awarded degrees. Besides, it included various ministers, their security and attending staff, doctors from the institute, residents, office workers, parent/family members of awardees, and other personnel involved in the conduction of the ceremony. There were also the engineering staff and event manager teams and catering staff. The target number of gathering was about 1000 people. The students were all health care professionals who were coming in from all over the country including Delhi, Maharashtra, Rajasthan, Kerala, Tamil Nadu, Uttar Pradesh, and other states.

A line listing of all attendees was done. The risk assessment of the attendees was done using screening measures. It had two phases: screening questionnaire and clinical assessment.

A total of 934 responses were received from the screening questionnaire circulated before the event day to the diverse population participating in the convocation from all over India [Table/Fig-1]. The age-wise distribution showed 60.2% in 21-40 years age group, 35.5% in 41-60 years age group, and 4.2% in 10-20 years and >60 years age groups. The responses were mostly negative for the questionnaire. Fifty-five people had affirmative responses were contacted again for detail clinical screening in the morning before the event started, and finally cleared for attending the convocation except one who had been hospitalised since she had a severe acute respiratory illness but later on found to be COVID-19 negative. Although the number of travellers to foreign countries was 14, the positive responders for the history of international travel to the COVID-19 areas were only two then. They were promptly advised to stay at home and it was ensured that they did. The clinical screening was also carried out among the suspect cases especially illiterate ground workers (cooks, tent workers, etc.) one day before the event. One worker was febrile but without any presenting complaints, hence hospitalised, but later on home isolated and recovery was seen.

Children were not allowed inside along with the attendees having chronic illnesses (previously informed through E-mails/WhatsApp/SMS). We had placed ample units of sanitisers for liberal use throughout the convocation venue and its use was mandatory at all the entry and exit sites. Everyone underwent thermal scanning for temperature recording and the suspects were also subjected to extensive history and examination before they were allowed to attend the event. Seating arrangements were such that all were seated with adequate distance between them. Repeated announcements were made regarding physical distancing, cough etiquette, and hand hygiene, along with the placement of multiple eye-catching banners regarding preventive steps. As per the clinician’s discretion, masks were provided, mostly to the elderly and all 55 high-risk attendees. Few attendees were found to be coughing, cough etiquettes were taught, and face masks offered. The gathering ended within four hours. Till 10^th April 2020, no attendees were hospitalised or found to be COVID-19 positive.

Among 930 people in the gathering of average four hours, no one developed any COVID-19 symptoms or positivity till 28 days of follow-up. This suggests near about 100% effectiveness of our prevention protocol for an organised mass gathering. Meticulous planning and efficient administrative work led to the successful conduct of a very large gathering. Instead of altogether stopping the gatherings, the conduction of gatherings in a planned and professional way as described is the way forward.

COVID-19 pandemic has deepened its roots in the world as of now. Despite months of lockdowns and restrictions, the pandemic is still on as of yet. Initial strategies were directed towards isolation and quarantine; the economies had suffered badly. People were facing dire shortages of food and all the necessary supplies. Therefore, the need of the hour was to re-open the society, although with restrictions. Hence, social gatherings were started. Instead of putting restrictions over gatherings, especially organised ones, they need to be managed systematically. Any decision to restrict, modify, postpone, cancel, or proceed with holding a mass gathering should be based on a rigorous risk assessment exercise, undertaken by the local authorities [2].

According to WHO guidelines (which were published after our gathering), the exercise should take into consideration the following points:

All these points were taken into consideration in the above planned mass gathering. WHO has also issued a risk assessment scoring system for evaluating the conduction of mass gatherings, which may be quite useful in this [4]. This is an operational tool that offers guidance for organisers holding meetings during the COVID-19 outbreak and this should be accompanied by the WHO COVID-19 generic risk assessment Excel file available on the WHO website [5]. Let’s apply this to our mass gathering risk assessment [Table/Fig-2].

Mitigation measures reduce the risk of COVID-19 virus transmission. Together with the risk assessment scores, the mitigation measures contribute to the decision matrix and influence the assessment of the total risk of transmission and further spread of COVID-19, and the recommendation as to whether the mass gathering should be held or not. They cover various aspects, including an understanding of the COVID-19 situation by the organisers, emergency preparedness and response plans, risk communication, and public health awareness of COVID-19 before and during the event. Our event’s organisers had quite a grasp on the ongoing COVID-19 pandemic, with excellent risk communication skills. Hence, the decision matrix result for this event could be considered “Very low risk”, which was excellent.

According to the Centers for Disease Control and Prevention (CDC) guidelines, various factors need to be considered before determining the need to postpone or cancel a large gathering: the overall number of attendees, the high-risk groups like older adults and persons with severe pre-existing health conditions who may be at an increased risk, the density of attendees within a confined area (virus mostly spreads person-to-person among close contacts within 6 feet), economic impact on attendees, staff, community, and local community level transmission to name a few [6]. All efforts should be made to significantly decrease the number of attendees. At a minimal-to-moderate level of community transmission, it is recommended to cancel community-wide mass gatherings (for example, >250 people; the cut-off threshold is at the discretion of community leadership based on the current circumstances the community is facing and the nature of the event) or move to smaller groupings. If the population belongs to a high-risk group, it is recommended to cancel gatherings of more than 10 people.

The CDC calls for the provision of COVID-19 preventive supplies to event staff and attendees including hand sanitiser with at least 60% alcohol, tissues, trash baskets, disposable facemasks, and cleaners and disinfectants. These supplies are essential for all mass gatherings. An older study demonstrated that the prevalence of viruses and bacteria increased from 7.4% and 15.4% before the Hajj to 45.4% and 31.0% after the Hajj [7]. This was due to the acquisition of rhinovirus, coronaviruses, influenza A H1N1, Streptococcus pneumoniae, Haemophilus influenzae, and Staphylococcus aureus. It was concluded that crowded conditions during mass gatherings such as the Hajj may contribute to the globalisation of respiratory pathogens after cross-contamination. During this COVID-19 outbreak, many such mass gatherings have resulted in an outburst of cases. Due to lack of prior publication of any protocol like ours, we couldn’t compare the results. However, in an organised gathering, it is expected to have better prevention than in an unorganised gathering. However, this protocol can be considered as proof of concept for all types of organisational gatherings. That doesn’t mean it can’t be used in an unorganised gathering since each gathering is actually a planned one by participants. Only awareness and practice of this protocol will help in preventing infections.

Our model had limitations. Our questionnaire did not include the attendees’ co-morbidities or any underlying conditions, however, through initial gathering notice; all were advised not to attend the event. Attendees could have fabricated false answers just to be able to attend the event. Hence, physical examination and temperature recordings of the attendees are quite important, just like we did. Because of asymptomatic transmission, this can fail the purpose. Also, adequate negative pressure ventilation could not be arranged for such a large gathering.

Although much of the scenario has changed since March 2020 and the total COVID-19 cases have surpassed the 1,00,00,000 mark in India, a well-planned and controlled gathering using the preventive protocol is a feasible and workable option. The present careful and meticulous planning of screening with a questionnaire, detailed examination of suspects and taking proper action, executing all possible precautions at the event, thermal screening of all entries, health education during the event, and follow-up till 28 days as done by us will certainly go a long way in averting a mass outbreak of cases. This prevention protocol can be used widely in organised gatherings. Any event to be held must be essential and unnecessary ones must be avoided, as the danger of mass exposure is still there. But the ones which are conducted should undergo proper planning and management as described. Only then can we start learning to live with this coronavirus scare. The farmers protest that has been staged in outskirts of the national capital of India is a glaring example of how disorganised and chaotic it can become as regards to the transmission of COVID-19. Heightened awareness coupled with the strategic plan of prevention needs to be inculcated among the masses who engage in protest, to prevent further damage. Many such strategies can be formulated keeping in mind the decreased awareness and motivation among mass gatherings among the specified gentry.