Three epidemiological studies were included in the systematic review, of which two were based on the 1918-1919 pandemic, and the third concerned World Youth Day 2008.
Both articles based on 1918-1919 pandemic found that timely bans on public gatherings and closure of public places appeared to reduce the excess death rate. However, it is impossible to determine the individual effects of measures to avoid crowding in these studies.
The effect of measures to avoid crowding alone in reducing transmission is uncertain.
There are differences in perception of expected outcomes from avoiding crowding among different populations. These differences are notable with respect to religious gatherings- some approve of avoiding religious activities if it could reduce influenza transmission, while others believed that avoiding gatherings might prevent receiving support from their religious community.
The abolition of religious gatherings may violate the faith of participants and make them feel morally guilty. It was believed that cancelling some events like the Hajj would not be possible.
Some people may oppose mandatory cancellation of religious gatherings, and violate restrictions on visiting shopping centres/ sporting events.
Quality of evidence: There is a very low overall quality of evidence on whether avoiding crowding can reduce transmission of influenza.
Overall strength of recommendation: Conditionally Recommended
Avoiding crowding during moderate and severe pandemics is conditionally recommended, with gradation of strategies linked with severity in order to increase the distance and reduce the density among populations.
The balance between the advantages and disadvantages of avoiding crowding is less certain, but may be justifiable in severe pandemics.
While most people in several countries followed advice to avoid crowding in the initial phases/ waves of pandemic COVID-19, their willingness to comply has progressively decreased over time. This is indicative of general fatigue with restrictions.
In some parts of the USA, people of a particular political affiliation have been very vocal about the infringement of their rights, and sometimes violently protested against imposition of restrictions on crowding.
In many parts of the world, people defied instructions to host/ participate in gatherings, resulting in several superspreading events. Unfortunately, participants in many of these events were later demonized and discriminated against.
Where religious gatherings resulted in superspreading events, the religious community involved sometimes faced public backlash. Politicians of certain ideologies used such events to create disharmony and blame the religious groups for rise in COVID-19 cases.
Simultaneously, fear of infection lead several religious leaders to suspend gatherings independent of government advice. The Hajj was also suspended, and places of worship closed. However, religious activities were transitioned to online platforms, with prayers live streamed on television channels and internet sites.
In some urban areas, law enforcement failed to cope with the large number of people violating restrictions on crowding. This lead to further spread of infection, the involvement of paramilitary forces, and imposition of curfew.
Despite increasing cases and evidence of community transmission, the general public is largely unwilling to continue adhering to restrictions on gatherings and crowding in public spaces. Therefore, these measures are best reserved for the initial containment phase of a pandemic. Imposing such measures over a prolonged period of time is unlikely to receive public support and cooperation.
Governments will have to justify the suspension of civil liberties, and may face legal challenges in the implementation of such measures. Even so, the use of force may be necessitated by public refusal to comply. This in turn can have far reaching consequences.
The effectiveness of this intervention is likely to be dependent on both its timing, as well as duration. A short, early intervention is likely to be more effective than a late, prolonged intervention.