Public Health: The Danger of Ending Social Distancing too Early

Published by Public Health Insider, a publication of Public Health Seattle - King County (PHSKC)

The danger of ending social distancing too early: A conversation with our Health Officer

By Meredith Li-Vollmer, PHSKC

You may have heard about a couple of recent studies that suggest that our social distancing measures appear to be making a difference in slowing the spread of COVID-19 in King County. That’s encouraging news.

The studies also emphasize that we need to continue to stay strong with the stay at home order if we are to continue to succeed in decreasing and delaying the outbreak peak. But we also see the enormous economic toll that social distancing orders are creating.

To understand more about where we are in the outbreak and what it would take to relax some of the social distancing measures, we asked our health officer, Dr. Jeff Duchin to talk about both the communicable disease aspects and undesirable consequences of COVID-19.

If the initial studies suggest that our efforts at social distancing are working to “flatten the curve,” why is it so important to stay steadfast with the Stay Home order and other social distancing measures?

People in King County deserve the credit for making a real difference in the course of this outbreak by staying at home and decreasing non-essential close contact with others. I understand how difficult this is. Everyone should know that these sacrifices are preventing many illnesses and deaths throughout our community, including family members, friends and loved ones, and co-workers.

The modeling done by IHME at the University of Washington is somewhat reassuring, but the conclusions are not certain. For example, the model assumes that our outbreak is similar to Wuhan, China and that the current social distancing efforts are unchanged over time. It doesn’t show what happens if people stop complying or are not as effective as they assume.

Our success at distancing has limited the number of people that have been infected, and that also means most of us remain susceptible to the virus. If we go back to business as usual, many people will be infected relatively quickly because COVID-19 remains circulating in the population. We remain at risk for a large outbreak that would overwhelm the healthcare system. That’s why the recent studies clearly state that we need to continue to stay strong with the Stay Home order for now.

No one should take these findings as an indication to relax our social distancing strategy at this time. The threat of a rebound that could overwhelm the healthcare system remains if we let up too soon.

What does it look like if the healthcare system is overwhelmed?

Right now we’re witnessing that in other places, such as New York City, where they are short on healthcare workers and critical resources to provide the usual level of care that people expect from our hospitals. And even though we’ve “flattened the curve” and decreased the number who are infected locally, our hospitals have needed to care for large numbers of COVID-19 patients, many of whom are seriously ill.

Because of our current success at distancing, today our hospitals are able to safely provide the usual level of care to the people who need it. This is also because of many major changes hospitals and healthcare systems have made to their usual operations in order to prepare to care for large numbers of COVID-19 cases.

But if we should get a dramatic spike in people who need to be hospitalized, it will badly stretch the system. In the worst scenarios, it could result in severe scarcity issues where it could be extremely difficult to meet the demand for lifesaving care. We must do everything we can to prevent getting to that level of crisis. It’s the most compelling reason to stay steady with social distancing as best we can.

There seems to be a local historical lesson from the influenza pandemic in 1918. What happened then and what can we learn from it?

During that influenza pandemic, the health officer and the mayor of Seattle put some pretty strong social distancing measures in place, and the city fared much better than other cities at the beginning. But when victory was declared in World War One, people emerged out of their homes in celebration, and then all the closures and prohibitions against mass gatherings ended. Shortly thereafter, there was a serious second wave of illness that lasted for several months. It’s a sobering lesson about the danger of prematurely relaxing social distancing.

At the same time, we need to consider the hardship that a prolonged Stay Home order could have on those who are struggling to get by. So we’ll be continually evaluating what aspects of social distancing need to stay in place, and what could be scaled back.

What needs to happen before social distancing measures could scale back?

When it appears safe, we will need to consider the gradual relaxing of one or more of our social distancing measures and carefully begin resume of our normal “pre-COVID-19” activities. These measures include the Governor’s Stay at Home order and school closures, cancellation of gatherings, and directive to stay six feet apart. During this time we will need to carefully monitor COVID-19 illnesses and deaths and our healthcare system’s ability to cope so that we can adjust course quickly if things head in a dangerous direction.

Some key indicators we’ll look closely at include:

How many people are getting sick from COVID-19:

We would want to see a steady decrease in the number of people getting sick and needing hospitalization for at least 2 weeks before we do anything that may make those numbers go up.

Health care system readiness:

When social distancing measures loosen, we should expect to see an increase in cases. We need to make sure our health care system has what it needs in terms of staff, bed space, medical supplies, and equipment to take care of the sick people in our community before we discontinue social distancing measures.

Testing:

Our ability to keep COVID-19 cases at a manageable level after relaxing social distancing measures requires widespread availability of rapid testing and reporting of results so that people who are infected can take quick action to prevent the spread of COVID-19. That is not yet available.

Testing is necessary to have the most accurate picture of the extent and spread of the outbreak to inform strategies for relaxing social distancing. Widespread testing is also necessary for public health disease investigation to decrease community spread of infection.

Public Health readiness:

Public health agencies will need capacity to do a large number of thorough case and contact investigations in order to identify people who are infected and their close contacts. This would be necessary so that these people are quickly isolated or quarantined in order to limit spread to others. This is the main thing that needs to happen to allow us to start resuming normal activities safely while avoiding a dangerous increase in new illnesses. People will need to understand the critical importance of isolating themselves when ill and rapidly helping inform their close contacts so they can quarantine themselves away from others and be tested if necessary based on guidance from public health.

To be successful, this work will need to occur at an unprecedented scale and speed, many times beyond what public health departments across the country can do currently. It requires a massive and rapid infusion of resources including disease investigators and information management tools.

Availability of proven treatments:

There are multiple therapies currently under evaluation to treat people with COVID-19, and the availability of these therapies will also be considered in our calculus of when to ease up on the mitigation measures.

How do we consider the threat of a rebound of COVID-19 along with the needs of the community?

We must continue to advocate for and provide support to those who are suffering from unintended economic and social impacts of this necessary disease control strategy.

If people cannot practice social distancing or stay in isolation and quarantine because they fear losing their jobs, or because there is no one to help them get the food or medication they need, not only are will they be at increased risk for infection but it will prolong and worsen the outbreak for all of us. The degree to which we can provide support for all of our residents so that they can make safe choices will have benefit to the entire community. This includes access to wage and employment security, food security, childcare, sustainable rent assistance and evictions protections, and paid sick leave. It also includes strong support for seniors and people with disabilities.

Small businesses should have access to grants and loans to keep business open should they need to close due to lack of staffing for a period of time while employees are recovering.

Keep in mind that we may be able to relax some measures while retaining others so that we can take a more measured approach. For example, it’s possible that the Stay Home order or school closures could be lifted while the directive to stay six feet apart will stay in place. It will depend on what the key indicators tell us about the safety of relaxing the measures.

For frequent updates on COVID-19, follow Public Health Insider or go to http://www.kingcounty.gov/covid.

Originally posted on Public Health Insider, a publication of Public Health Seattle - King County on April 10, 2020.