Editor's Note: This is a complimentary research note published by Healthcare Policy analyst Emily Evans. The information presented here is based on a time series we constructed at the county, Metro and state levels. CLICK HERE to get daily COVID-19 analysis and alerts from our research team and access our related webcasts
At the daily COVID-19 task force briefing on Tuesday the Trump administration gave us a few more hints about the future. Meanwhile, Dr. Tom Frieden, former CDC Director under President Obama and an infectious disease specialist, released his plan for “re-opening” the American economy, following a similar outline released by the American Enterprise Institute last week.
Things are slowly coming into focus.
The administration’s hints on the post-April 30 are these:
When asked when American’s would be able to relax social distancing measures, Dr. Tony Fauci said, “when we get to the other side of the curve.” We have made the point regularly, as have Dr. Birx and Dr. Fauci, that public health is a locally managed effort. So, there are possibly 3,000 county-level and 50 state-level curves that are going to determine when local health officials begin to relax social distancing standards.
The second hint involved the development at the State level of a surveillance system for COVID-19 cases. The CDC currently funds 50-70% of state health departments, which in turn fund local agencies. The State health departments have in place a reporting system for flu and flu-like symptoms that is being expanded and enhanced for identification and reporting of COVID-19 cases. Such as system will be critical to staying on the other side of the curve and suppressing outbreaks until a therapeutic/vaccine is available.
Ahead of the Curve
Naturally, Metro areas and states that experienced outbreaks earlier and implemented public health responses sooner are seeing the results and bending the curve. Seattle and the San Jose-Santa Clara Co. CA community have both been able to slow their new case growth in a meaningful way while other MSAs have struggled to keep it under control.
New York City is also showing signs that it may be approaching the turn in the curve (with the necessary caveat produced by the example of Boston below). Day to day changes in cumulative caseload are declining. Meanwhile the aforementioned monitoring system for Influenza-like Illness and Respiratory Symptoms, which picked up an increase in activity associated with COVID-19 early in March, has also turned down.
Although the trends in New York, Northern California and Seattle appear durable, we must, as we have done with this data since the beginning, caution against early reactions. Boston, which appeared to be getting an outbreak under control in mid-month but has struggled to produce a consistent trend and get the DoD% Change under 10%.
Managing the “Other Side”
There can be little doubt that economics and politics dictate a return to some operating level sooner rather than later. We suspect that the White House was talked into a 30-day extension of their Social Distancing guidelines as a way to limit the economic damage that is associated with a return to normalcy too soon. We have difficulty imagining another extension and we hear from Governors and the president’s advisors that they do also. We also have difficulty seeing a broad and sudden reduction in social distancing requirements in the US.
Instead, we anticipate that the White House and the CDC will develop guidelines for states for a phased in approach to the reduction in restrictions. This phased-in approach will be along the lines of Dr. Gottlieb’s vision published by the American Enterprise Institute and Dr. Frieden’s recently published plan.
The plan, whether it follows the more demanding contours AEI or Dr. Frieden’s plan, will have trigger points for each phase of recovery. Initially, there seems to be consensus that caseload declines for 14 consecutive days in the context of greater testing or no declines in caseload but a reduction in positive tests would be a good place to begin relaxing standards.
One complexity in “re-opening” a state is that they all have varying testing capacities and wildly different positive rates. States like New York are doing a massive number of tests but are recording high positive rates, suggesting the disease is widespread. Washington, which has the disease under control has also done a great deal of testing with a much lower positive rate.
A state like Washington, and specifically the Seattle area, are likely to be able to implement relaxation of social distancing in May. A state like New York will have to wait longer as it works to reduce the caseload for 14 consecutive days or drive the positive rate down.
Another factor is going to be the varying experiences a state like California has had. San Francisco and the San Jose area have managed the disease well while Los Angeles has had a different experience. As eight bay area counties adopted a shelter-in-place prior to the same move by Governor Newsom, one would expect they could unwind social distancing measures in a similar way.
Further complicating the return to normalcy is the varying health care and public health capacity in American communities. Predicated on “re-opening” a state or local economy will be both the presence of the health care infrastructure in terms of ICU beds, oxygen support equipment and trained clinicians and the public health surveillance system to test symptomatic individuals and contact trace asymptomatic carriers.
Unfortunately, there are several recently emerged hotspots like Albany, GA, New Orleans, LA and East Stroudsburg, PA which now have hundreds of cases per 100,000. Unfortunately, the Albany, GA MSA has a mere 1,000 beds and East Stroudsburg has 277. New Orleans is a bit better prepared with 8,000 inpatient beds in the MSA but a host of other challenges that ensure it will be a long slog to resolution.
However, it is clear from the reporting systems various state health departments have stood up the last several weeks that developing a robust reporting system is a top priority. Dr. Birx included this project in her remarks at Tuesday’s briefing.
We have also learned that states who have the disease under control, like Washington, have moved to testing, contact tracing and containment and are prepared for the necessary transition to more relaxed social distancing measures.
So, be prepared for a rolling implementation of first, modest relaxation of social distancing requirements then moving on to more significant measures, provided the public health system can test, trace and contain small outbreaks of the disease. Based on the policy plans put forward thus far, we developed a theoretical absolutely best case, model citizen scenario:
As we always say, the situation is fluid, but I continue to get ever so slightly more optimistic that there will be some return to normal operations somewhere in May.