Same-day SARS-CoV-2 an igen es sc eening in an indoo mass-ga he ing li e music
e en . A andomized con olled ial.
Bo is Re ollo, MD, PhD1, Ignacio Blanco, MD, PhD2, Pablo Sole , LLB3, Jessica To o1,
Nu ia Izquie do-Use os, PhD4,5, Jo di Puig1, Xa ie Puig, PhD6, Valen í Na a o, Msc7,
C is ina Casañ, Pha mG2, Lidia Ruiz, PhD4, Daniel Pe ez-Zsol , PhD4,5, Sebas ià Videla,
MD, PhD1,8, Bona en u a Clo e , MD, PhD1,4,9,10, Josep M Llib e MD, PhD1.
1 Di ision o In ec ious diseases and Founda ion o Figh ing AIDS, In ec ious Diseases
and P omo ing Heal h and Science, Uni e si y Hospi al Ge mans T ias i Pujol, Badalona,
Spain.
2Me opoli ana No d Labo a o y, Ins i u Ca alà de la Salu , Badalona, Spain.
3P ima e a Sound G oup, Ba celona, Spain
4I siCaixa AIDS Resea ch Ins i u e, Uni e si y Hospi al Ge mans T ias i Pujol, Badalona,
Spain.
5Ge mans T ias i Pujol Resea ch Ins i u e (IGTP), Can Ru i Campus, Badalona, Spain
6Depa men o S a is ics and Ope a ions Resea ch. Uni e si a Poli ècnica de
Ca alunya-Ba celonaTech, Ba celona, Spain.
7Clinical Resea ch Uni . Ins i u Ca alà d'Oncologia, Bell i ge Biomedical Resea ch
Ins i u e (IDIBELL), L'Hospi ale de Llob ega , Spain
8 Clinical Resea ch Suppo Uni , Clinical Pha macology Depa men , Bell i ge Uni e si y
Hospi al / Bell i ge Biomedical Resea ch Ins i u e (IDIBELL) / Uni e si y o Ba celona,
L'Hospi ale de Llob ega , Ba celona, Spain.
9Uni e si a de Vic-Uni e si a Cen al de Ca alunya (UVIC-UCC).
10 Uni e si a Au ònoma de Ba celona. Ba celona, Spain
Keywo ds: Co id-19, SARS-CoV-2, mass e en s; supe sp eading e en s; conce s; SARS-
CoV-2 an igen es ; RT-PCR; ansc ip ion-media ed ampli ica ion.
Wo d coun : 3940 Tables: 1 Figu es: 2 Suppl Table: 2
Running i le: SARS-CoV-2 ansmission in a li e conce .
Funding: Funded by P ima e a Sound G oup (Ba celona, Spain) and #Yomeco ono
Ini ia i e (h ps://www.yomeco ono.com/), Ba celona, Spain.
Decla a ion o In e es s: The au ho s decla e no con lic s o in e es .
Au ho Con ibu ions: B.R., S.V., B.C. and J.M.L. concei ed he p ojec and designed
he s udy. P.S. ec ui ed pa icipan s and o ganized he enue amewo k. J.P.
sc eened i ological es s o all pa icipan s. J.T. managed he da abase. X.P. and V.N.
pe o med s a is ical analyses. I.B. and C.C. pe o med labo a o y analyses on clinical
samples. N.I. and D.P-Z. pe o med SARS-CoV-2 cell cul u es. J.T., J.P., B.R., and J.M.L.
accessed and e i ied he da a. BR and J.M.L. w o e he pape . All au ho s had he
oppo uni y o discuss he esul s and commen on he manusc ip .
Co esponding au ho :
D Josep M Llib e
In ec ious Diseases Di ision
Hospi al Uni e si a i Ge mans T ias
C a de Canye s/n; 08916 Badalona. Spain
E-mail: [email p o ec ed]; el: +34 934978887.
Resea ch in con ex
E idence be o e his s udy
On Ma ch 30, 2021, we sea ched PubMed using he e ms mass-ga he ing e en and COVID-
19. The sea ch e u ned 31 esul s, mos o hem co esponding o a icles ha ei he
desc ibed mi iga ion plans o epo ed e ospec i e analyses o SARS-CoV-2 sp ead du ing
mass-ga he ing e en s. None o he a icles ound epo ed he esul s o a con olled
expe imen in which p e en i e measu es we e used o c ea e a sa e en i onmen du ing a
mass-ga he ing e en .
Added alue o his s udy
We andomized 1,140 indi iduals wi h a nega i e an igen apid diagnos ic es (Ag-RDT) o
ei he a end an indoo li e music e en o i e hou s o e u n o egula li e. All pa icipan s
we e sc eened as well wi h a RT-PCR and cellula i al cul u e (Ve o E6 cells) in all posi i e RT-
PCR samples. The enue had 1,024 m2 and ac i e ai en ila ion, and a endees had o wea a
acial mask excep when d inking (alcoholic be e ages we e allowed). Eigh days a e he
e en , no SARS-CoV-2 in ec ions could be con i med among a endees, whe eas wo PCR-
con i med in ec ions we e epo ed in he con ol g oup. Acco ding o he Bayesian analysis,
no signi ican di e ences we e ound be ween he incidence in he wo g oups.
Implica ions o all he a ailable e idence
Ou s udy p o ides p elimina y e idence on he e ec i eness o same-day poin -o -ca e
sc eening wi h Ag-RDT, combined wi h ace mask-wea ing and ac i e ai en ila ion, o c ea e
sa e indoo en i onmen s wi h no need o physical dis ancing measu es. Fu u e s udies wi h
la ge samples and/o conduc ed in a con ex o highe COVID-19 incidence a e wa an ed.
Abs ac
Backg ound
The banning o mass-ga he ing indoo e en s o p e en SARS-CoV-2 sp ead cause an
impo an impac on local economies. Despi e g owing e idence on he sui abili y o an igen-
de ec ing apid diagnos ic es s (Ag-RDT) o mass sc eening a he e en en y, his s a egy
has no been assessed unde con olled condi ions.
Me hods
We designed a andomized-con olled open-label ial o assess he e ec i eness o a
comp ehensi e p e en i e in e en ion o a mass-ga he ing indoo e en (a li e conce )
based on sys ema ic same-day sc eening o a endees wi h Ag-RDTs, use o acial masks, and
adequa e ai en ila ion. Indi iduals wi h nega i e Ag-RDT esul s we e andomized 1:1 (block
andomisa ion s a i ied by age and gende ) o ei he a end he indoo e en o i e hou s o
no . Nasopha yngeal specimens used o Ag-RDT sc eening we e analyzed by RT-PCR and cell
cul u e (Ve o E6 cells). Eigh days a e he e en , a nasopha yngeal swab was collec ed and
analyzed by Ag-RDT, RT-PCR, and TMA. The p ima y ou come was he di e ence in incidence
o RT-PCR-con i med SARS-CoV-2 in ec ion a 8 days be ween he con ol and he in e en ion
g oups.
Findings
The analysis included 960 pa icipan s: 495 in he con ol a m and 465 in he in e en ion a m.
Pa icipan s in he in e en ion a m spen a median o 2 hou s and 40 minu es inside he
conce . A baseline, 15 (3·0%) o indi iduals in he con ol a m and 13 (2·8%) in he
in e en ion a m es ed posi i e on TMA despi e he nega i e Ag-RDT esul . The RT-PCR es
was posi i e in one case in each a m; cell i al cul u e was nega i e in all cases. Eigh days a e
he e en , 2 (4·0%) indi iduals in he con ol a m had a posi i e Ag-RDT and PCR esul ,
whe eas no Ag-RDT no PCR posi i e esul s we e ound in he in e en ion a m. The Bayesian
es ima e o he incidence be ween he con ol and expe imen al a ms was -0·15% (95% CI -
0·72% o 0·44%).
In e p e a ion
Ou s udy p o ides p elimina y e idence on he sa e y o indoo mass-ga he ing e en s
conduc ed du ing a COVID-19 ou b eak unde a comp ehensi e p e en i e in e en ion.
Funding
The s udy was unded by P ima e a Sound G oup (Ba celona, Spain) and he #Yomeco ono
Ini ia i e (h ps://www.yomeco ono.com/), Ba celona, Spain.
(ClinicalT ials.go numbe , NCT04668625)
In oduc ion
Mass-ga he ing e en s a e associa ed wi h a high isk o sp eading he se e e acu e espi a o y
synd ome co ona i us 2 (SARS-CoV-2).1–3 Cul u al ac i i ies like a spo ing e en , indoo
ga he ing pa ies, play, o conce s ha e been poin ed among he iskies ac i i ies o SARS-
CoV-2 ansmission.4 Heal hca e au ho i ies ha e co espondingly educed he capaci y o he
enues o p e en close con ac be ween unknown a endees o ha e e en cancelled all he
e en s, despi e he lack o scien i ic e idence o such inc eased isk in some cases.5
O all mass-ga he ing e en s banned du ing he COVID-19 pandemic, he closu e o conce
halls has had a ema kable impac on local economies. In 2019, music es i als had an
es ima ed e enue o mo e han 5,500 million € in Spain and 2,500 million in Ca alonia. The
cancela ion and de e men o hese e en s in 2020 has caused subs an ial economic losses,
and es ic ions on hei celeb a ion o capaci y emain in o ce in 2021.6
One o he key ac o s ha challenge he con ol o massi e SARS-CoV-2 ansmission in mass-
ga he ing e en s is he di icul y in iden i ying indi iduals wi h in ec ion capaci y, pa icula ly
asymp oma ic o p e-symp oma ic indi iduals wi h a high i al load.7 SARS-CoV-2
ansmissibili y begins 2 o 3 days be o e symp om onse , and i is es ima ed ha nea ly hal o
he ansmissions occu om asymp oma ic indi iduals.3,8
The long u na ound o nucleic-acid ampli ica ion es s (NAAT)―including he gold s anda d
eal- ime e e se ansc ip ase-polyme ase chain eac ion (RT-PCR)― o iden i ying he SARS-
CoV-2 in espi a o y specimens hampe s implemen ing mass es ing s a egies on he same
day o he e en . Al e na i ely, an igen-de ec ing apid diagnos ic es s (Ag-RDTs) ha e been
p oposed as sui able ools o poin -o -ca e sc eening o SARS-CoV-2 in ec ed indi iduals. The
main ad an ages o Ag-RDTs include low p ice, absence o need o high- ech labo a o y
e e al, and a sho u na ound ime o p o ide a esul . Despi e he o e all lowe sensi i i y
o Ag-RDTs compa ed wi h NAAT, a g owing body o e idence indica es ha hey a e sui able
o iden i ying indi iduals wi h ansmission capaci y.9–11
Cu en e idence on Ag-RDT pe o mance sugges s ha a poin -o -ca e sc eening o
con agious indi iduals, oge he wi h con ainmen measu es like he use o adequa e acial
masks and op imized en ila ion can c ea e sa e en i onmen s o pe o ming mass-ga he ing
e en s wi h a low isk o SARS-CoV-2 sp ead. Ne e heless, his app oach has no been es ed
unde con olled condi ions. We conduc ed a andomized con olled ial o assess he
e ec i eness o a p e en ing s a egy o a li e indoo conce unde he hypo hesis ha a
same-day poin -o -ca e sc eening o in ec ed indi iduals and egula p e en i e measu es
would p e en an inc eased isk o SARS-CoV-2 ansmission du ing he e en .
Me hods
S udy Design and Pa icipan s.
This was an open-label, andomized (1:1) clinical ial o assess he e ec i eness o a
comp ehensi e in e en ion o p e en SARS-CoV-2 sp ead du ing an indoo li e conce
(Supplemen a y Appendix 1). S udy pa icipan s we e ec ui ed om a lis o subsc ibe s o
news ela ed o li e music e en s; a call o en olling in he s udy was pe o med h ough non-
o icial media like Wha sApp, Teleg am, o email. Eligible pa icipan s we e adul s aged 18 o
59 yea s wi h a nega i e esul in an Ag-RDT pe o med on a nasopha yngeal swab collec ed
immedia ely be o e en e ing he e en . Pa icipan s wi h known COVID-19 diagnosis wi hin he
14 days be o e he e en , ele an como bidi ies, o li ing wi h olde people we e excluded.
Supplemen a y Appendix 2 p o ides a comple e lis o selec ion c i e ia.
SARS-CoV-2 sc eening and andomiza ion
F om 9 hou s be o e s a ing he e en , he heal hca e s a (45 nu ses and 1 physician)
collec ed nasopha yngeal swabs om all eligible pa icipan s in a sc eening s uc u e se up
ou doo s in on o he conce enue, wi h 24 awnings. The same nasopha yngeal specimen
was used o pe o m in si u Ag-RDT (Panbio™ COVID-19 Ag Rapid Tes , Abbo ) and a
ansc ip ion-media ed ampli ica ion es (TMA, P ocleix Pan he ®, G i ols). The TMA esul
was epo ed 24 o 48 hou s a e ending he e en . All TMA-posi i e samples we e e- es ed
by RT-PCR. The day a e eleasing he esul , all TMA-posi i e indi iduals we e con ac ed by
phone o a s uc u ed in e iew by a physician, and hei elec onic medical eco ds we e
sc eened o iden i y he exac da e o a p io posi i e SARS-CoV-2 diagnos ic es . All swabs
wi h posi i e TMA esul s we e assessed o i al isola ion on cell cul u e. All s udy pa icipan s
we e isi ed 8 days a e he e en o nasopha yngeal swab collec ion and TMA es ( ollow-
up day 8 es ). Acco ding o cu en e idence on SARS-CoV-2 kine ics, an assessmen
pe o med on day 8 maximizes he likelihood o cap u ing in ec ions caused du ing he li e
e en .8,12,13
S udy pa icipan s wi h a nega i e esul on Ag-RDT we e andomly assigned 1:1 o ei he
en e he indoo li e e en (expe imen al a m) o no en e ing he e en and e u ning o
no mal li e (con ol a m). The compu e -gene a ed block andomiza ion (REDCap™ module)
was s a i ied by age, gende , and p e ious COVID-19 in he ques ionnai e.
Indoo e en p ocedu es
All pa icipan s ins alled wo sma phone applica ions (apps). The “Rada Co id” (a con ac
acing app) was in ended o cap u e close con ac s o subjec s po en ially in ec ed du ing he
conce . The “Tes -Walle ” app was used o con iden ially epo he s udy es esul s (i.e., Ag-
RDT, TMA, and PCR) and ill a heal h ques ionnai e be o e and en days a e he e en , and a
sa is ac ion ques ionnai e o hose a ending he conce (Supplemen a y Appendix 3). Da a
gene a ed by he Tes -Walle app we e enc yp ed using SHA-1 enc yp ion and wi h 256-bi SSL
secu i y ce i ica e. All SARS-CoV-2 posi i e esul s we e epo ed in o he public heal h
elec onic sys em and igge ed qua an ining measu es and con ac acing s udies.
All pa icipan s ecei ed an N95 mask a he enue en ance. Mask wea ing was manda o y
du ing he en i e e en . No physical dis ancing was equi ed in he conce oom (wi h a
capaci y o 900 pe sons); singing and dancing we e pe mi ed. A smoking a ea was se
ou doo s; he a ea had 20 people capaci y and s ic con ol o c owding and physical
dis ancing.
D inks―including alcoholic be e ages―we e se ed only in he ba zone, loca ed in a
supplemen a y oom wi h a capaci y o 1,600 people. Pa icipan s we e asked o emo e hei
ace mask only when d inking. People mo emen s inside he enue we e p e iously de ined
and signaled. Secu i ies pe sonnel o e saw all mo emen s and ook acons―i necessa y― o
p e en queues in and a ound he enue oye and oile s. Hyd oalcoholic hand sani ize gel
was p o ided a mul iple poin s in he enue.
The empe a u e o he dancing oom and ba we e main ained be ween 19·3 and 20·4 ºC
du ing he e en o acili a e wea ing he mask and coa s ( he cloak oom was closed o a oid
queues in on o i ). A e age CO2 measu emen s be o e s a ing he e en we e 440 ppm in
he dancing hall and 417 ppm in he ba oom, bo h simila o hose ypically ob ained on open
ai in he ci y. Public heal h sa e y guidance in o ce a he ime o he e en ecommended no
exceeding 800-1,000 ppm du ing he e en .14
The o al su ace o he enue was 1,024 m²: 228 m² o he dancing hall, 381 m² he ba hall,
and 157 m² in he lobby. The e we e no ou e windows in he wo espec i e halls; howe e ,
all access and exi doo s emained open du ing he e en , allowing addi ional esh ai om
he inne cou ya d.
The e en , held in he Sala Apolo (Ba celona, Spain) on Decembe 12, 2020, las ed o i e
hou s and included ou pe o mances: wo DJ sessions and wo li e music ac s. Besides he
s udy pa icipan s and a is s, 58 s a membe s (o ganize s, secu i y, sound, ligh echnicians,
and ba ende s) we e inside he enue du ing he e en . All o hem we e es ed o SARS-
CoV-2 using Ag-RDT a he same ime poin s as s udy pa icipan s.
Labo a o y assessmen s
Nasopha yngeal specimens we e collec ed wi h locked swabs in a i al uni e sal anspo
medium (Del alab S.L, Ba celona, Spain). Samples we e ecei ed a he labo a o y and we e
p ocessed immedia ely, inac i a ed, and analyzed by TMA. All TMA-posi i e esul s we e
con i med by RT-PCR assay o de e mine he cycle h eshold (C ) alues (AllplexTM® SARS-CoV-
2, Seegene) using he so wa e designed by he company. Le o e posi i es samples we e
conse ed a -80°C.
Nasopha yngeal specimens wi h posi i e SARS-CoV-2 TMA esul s despi e es ing nega i e on
Ag-RDT we e analyzed o i al isola ion on cell cul u e. Ve o E6 cells (ATCC CRL-1586) we e
cul u ed in Dulbecco’s modi ied Eagle medium (DMEM) supplemen ed wi h 10% hea
inac i a ed e al bo ine se um (FBS), 100 U/mL penicillin and 100 µg/mL s ep omycin
(In i ogen®). Two indi iduals wi h nega i e SARS-CoV-2 RT-PCR, and wo i al s ocks
p e iously isola ed we e cul u ed in iplica es as nega i e con ols as p e iously desc ibed.15
DMEM supplemen ed wi h FBS and Pen/S ep we e supplied o cells and inspec ed e e y 2
days o cy opa hic e ec s. On day se en, cell supe na an s we e assayed wi h a high-
sensi i i y quan i a i e ELISA o SARS-CoV-2 nucleocapsid p o ein (ImmunoDiagnos ics®).
E hics
The s udy was app o ed by he E hics and Clinical Resea ch Commi ee o he Hospi al
Uni e si a i Ge mans T ias in Badalona, Spain. All subjec s signed elec onically an in o med
consen (Signa u i ®). The s udy was conduc ed acco ding o he Decla a ion o Helsinki and
local legisla ion and is egis e ed a ClinicalT ials.go : NCT04668625.
Anonymized da a a e ully a ailable upon easonable eques om he co esponding au ho
a e app o al by he hospi al E hics Commi ee.
S a is ical analysis
The p ima y e icacy endpoin was he di e ence in incidence o RT-PCR-con i med SARS-CoV-
2 in ec ion a 8 days be ween he con ol and he in e en ion g oups. I was assessed in he
ull analysis se , which included all pa icipan s who we e andomly assigned, a ended he
e en (in he expe imen al a m), and had a alid esul in he day 8 ollow-up SARS-CoV-2 es .
We used a Bayesian be a-binomial model o analyze he numbe o in ec ed cases in each
g oup. This app oach allows p io in o ma ion o be included, which is use ul when es ima ing
he p obabili y o a e e en s16,17.
The se en days cumula i e incidence obse ed in he ci y o Ba celona when he second RT-
PCR was ca ied ou was a ound 1.3 pe housand people, acco ding o o icial da a.14
Howe e , his alue unde es ima es he ue a es due o he di icul y in eco ding
asymp oma ic cases. On he o he hand, he s udy popula ion had some exclusion/inclusion
c i e ia ha could in luence his alue. Fo he con ol g oup, he p io dis ibu ion chosen was
a Be a(1.1, 400), wi h median 0.002, and he p obabili y o alues g ea e han 0.01 is
app oxima ely 2%. Unce ain y abou he p obabili y o in ec ion among he expe imen al
g oup was highe , and a Be a(1, 28.4) was chosen, wi h a p obabili y o ob aining alues
g ea e han 0.1 a ound 5% as a p io dis ibu ion. Fo each g oup he pos e io median and
he highes pos e io densi y in e al we e calcula ed. In addi ion, o compa e he p obabili ies
o in ec ion be ween g oups, he di e ence in hei p obabili ies and i s c edible in e al (CI)
we e calcula ed.
The nega i e p edic i e alue o he Ag-RDT was es ima ed, aking as e e ence es s he RT-
PCR and cell cul u e and using he Bayesian Ma ko Chain Mon e Ca lo (MCMC) me hod as
p oposed by Gelman e al18. Fo he p e alence, a Be a(1.1, 400) was chosen again as a p io
dis ibu ion, and he sensi i i y and speci ici y a e gi en wi h a non-in o ma i e Be a(1 1)
p io s. The median and he highes pos e io densi y CI we e calcula ed o he nega i e
p edic i e alue.
The analyses we e pe o med using R and he Bayesian so wa e JAGS 19,20.
Role o he unding sou ce
The sponso o he s udy had no ole in s udy design, da a collec ion, da a analysis, da a
in e p e a ion, o w i ing o he epo . The co esponding au ho had ull access o all he da a
in he s udy and had inal esponsibili y o he decision o submi o publica ion.
Table 1. Resul s o he i ological assessmen s o SARS-CoV-2 a baseline and day 8
a e he e en .
Figu e 1. T ial p o ile.
Figu e 2. Incidence o SARS-CoV-2 in ec ion in he wo s udy a ms (con ol a m
N=495; in e en ion a m N=465). A: Bayesian es ima e o he incidence di e ence
be ween he expe imen al and con ol a ms. B: obse ed e en s (ba s) and es ima ed
(Bayesian app oach) in ec ion a e pe 100 people (do s) wi h he 95% c edible in e al
(e o ba s).
Supplemen a y Appendix 1. S udy design cha .
Supplemen a y Appendix 2. Inclusion and exclusion c i e ia o pa icipan s.
Supplemen a y Appendix 3. Day 0 and Day 10 heal h ques ionnai e.
Re e ences.
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