This week has been one of cancellations to stem the coronavirus pandemic. The Philadelphia Orchestra, Sixers, Flyers, St. Patrick’s Day parade, all cancelled. Pennsylvania public schools, cancelled. Public gatherings, gone.

As emergency physicians working in Penn Medicine’s ERs, we have been gearing up to manage the inevitable influx of patients. And now, the weekend is here, and we have had to ask ourselves: Should we attend that weekly large gathering that is so important to so many of us?

The foundational aspect of faith in the lives of many Philadelphians makes cancelling church fundamentally different from shutting down entertainment or work functions. Sunday mornings are a sacred time of community, going to the core of identity and belonging. In this time of chaos, uncertainty, and gloom, faith and religious gatherings can provide peace, purpose, and fellowship.

However, it is for these reasons that church, and religious gatherings in general, are among the highest risk venues, as otherwise isolated older adults come into close contact with socially active younger adults and children who may carry the coronavirus asymptomatically. Initial outbreaks in South Korea and Iran originated in religious gatherings. In Italy, initial steps to reduce transmission risk at mass escalated to cancelling mass altogether as transmission exploded.

Why is it so imperative that aggressive steps be taken now to limit social contact in U.S. religious gatherings? The severe lack of availability of tests means we as physicians cannot test and quarantine symptomatic patients who are not sick enough to be hospitalized or do not meet strict exposure criteria. As a result, there are likely to be many undiagnosed patients actively spreading the virus. The most powerful mitigation tool is aggressively limiting social and physical contact to slow the spread of disease and prevent overwhelming Philadelphia’s already strained hospitals in the weeks to come.

The decision to hold religious gatherings and maintain religious practices must be weighed against the potentially stark consequences that could arise from an outbreak, including severe illness or even death among the congregation. Among those aged 80 and older, 1 in 7 who get infected have died. COVID19 is transmitted from person-to-person contact (within 6 feet of each other) by respiratory droplets and can spread from contaminated surfaces and touching ones mouth, nose, and eyes. Cancelling church services is the only way to fully ensure these gatherings are not the focal point of an outbreak, and some churches have already taken this step.

Over the coming days, many more may choose to follow suit, and there is a possibility that the city could mandate closure. Short of full closure, however, there are measures church leaders can take to lead their congregations safely in this time of unprecedented pandemic. We offer this public health guidance adapted to the church setting to both counter fear that is circulating, and help mitigate the risk of disease. While these recommendations are based on our Christian faith backgrounds, the general principles can apply to other faith traditions.

Religious leaders, tell your congregation it is okay not to attend services. Those with any infectious symptoms of COVID19 must not attend. The Archdiocese of Philadelphia has dispensed Catholics from the obligation of attending Sunday Mass. This simple act relieves churchgoers weighing the risk of attendance against the guilt or uncertainty of staying home. We also recommend advising those at highest risk to not come to service at all. In accordance with CDC guidelines, this would include people over age 60, people with immune compromise, and people with underlying medical problems such as cardiovascular disease, diabetes, respiratory problems, or high blood pressure.

Churches should cancel any events not directly related to Sunday services. For example, Bible study, choir practice, and the coffee hour that often happens after Sunday service. If gatherings are being held, tell people ahead of time not to hug, kiss, or shake hands and try to maintain a 6-foot distance from each other. Leaders can model alternative ways to socially acknowledge each other, such as a slight bow. We applaud the measures taken last week to reduce transmission via distribution of blessed sacraments. Ensuring eucharistic ministers wash their hands before distributing communion, and requiring all to use hand sanitizer pumps placed in the aisle prior to receiving communion could reduce the risk of transmission.

In the age of technology, there are many ways to stay connected to each other virtually. Many churches already live-stream services, and we encourage all churches to plan for this in the event that services do need to be cancelled. Live stream is also a great option to ensure participation for people who choose to stay home. For example, for the first time this Sunday, St. Marks Church will use Facebook to live stream service. Churches can also consider holding daily group prayer calls and bible studies with free tele/video conferencing services, and group text chats with a service such as GroupMe. Church leadership can also plan for individual calls or visits to seniors who may not be comfortable using technology, but who are at greatest risk of social isolation.

In times of uncertainty, church is often a place for stability, answers, and peace. But Jesus himself did not have a church building, and church is not defined by a Sunday morning service. As we adapt to the rapidly changing Coronavirus pandemic, let's remember that church is the people, and minimizing contact during this pandemic is an act of charity.

Eugenia C. South, MD, MS, (@Eugenia_South) is assistant professor of emergency medicine and M. Kit Delgado, MD, MS, (@kit_delgadoMD) is assistant professor of emergency medicine and epidemiology at the University of Pennsylvania, Perelman School of Medicine.