We and Our Leaders Can Control COVID

Excitement is in the air. It is spring, people are being vaccinated, and we all anticipate a speedy end to the crisis. But wait, there’s more. It will be weeks before everyone who is willing is vaccinated, and there are variants which the vaccine may not protect us from. We all need to continue taking every precaution for weeks to come. Together, we can survive the pandemic, and the governor should reconsider his policies on reopening and enforcement.

Caution is most important for elderly people, including those living in public or subsidized housing, because we are the most vulnerable to the severe outcomes of COVID.

“For the two week period prior to April 14, 2021, the average age of Massachusetts residents who have died from COVID-19 was 74 years old.”

Weather forecasters talk a lot about the weather, sometimes they can predict it, but they can't control it. Neither can we control the weather, but in our homes we may use a thermostat to control the heating and cooling devices to maintain a comfortable temperature. We use a measure of the present temperature to create a future temperature.

Our leaders should do more than predict what they hope will happen with COVID, because they have the power to control it to some extent.

We know that when people gather indoors, people are infected. We know that when everyone is masked, infections are prevented. We can predict the outcome. We know this because these connections have been documented during the pandemic.

Mandating masks was associated with a decrease in daily COVID-19 case and death growth rates within 20 days of implementation. Allowing on-premises restaurant dining was associated with an increase in daily COVID-19 case growth rates 41–100 days after implementation and an increase in daily death growth rates 61–100 days after implementation.--- Guy GP Jr., Lee FC, Sunshine G, et al. Association of State-Issued Mask Mandates and Allowing On-Premises Restaurant Dining with County-Level COVID-19 Case and Death Growth Rates — United States, March 1–December 31, 2020. MMWR Morb Mortal Wkly Rep 2021;70:350–354.

We have the power to control the outcome for ourselves and for all those we come into contact with. We can avoid indoor gatherings and we can always wear a mask and maintain social distance, and take care of personal and building hygiene. No one thing can protect us, not even vaccination, but the more barriers we have, the safer we will be. For us to stay safe, we need to comply with the mandates, and the Governor and the Department of Public Health need to be cognizant of how a virus spreads; the more people who are infected, the greater the ability of the virus to infect more people. Even a very low rate of infection can ramp up exponentially—very quickly.

We have tools to measure the size of the infection by the COVID virus. We also have tools for control that can restrict the ability of the virus to spread: vaccination, masking, distancing, personal and building hygiene, and limits on risky types of gathering such as indoor dining.

The Governor has vast emergency powers to decree masking, distancing, and to specify the number of people that can gather. Does he use the power well? We can know by looking at the results of his policy.

The reopening

The Governor moved to reopen, effective March 22, enabling larger numbers of people to gather.

Today, the Baker-Polito Administration announced that Massachusetts will advance to Step 1 of Phase IV of the Commonwealth’s reopening plan on Monday, March 22. The Administration continues to take steps to reopen the Commonwealth's economy with public health metrics continuing to trend in a positive direction. This includes drops in average daily COVID cases and hospitalizations. Massachusetts also continues to be a national leader in vaccination rates. The Administration also replaced the Massachusetts Travel Order originally issued in July 2020 with a Travel Advisory, effective March 22. Sarah Finlaw, Press Secretary, Governor's Office, Press release, March 18, 2021.

The reasons cited to justify the reopening are based on a simple error: they are based on outcomes, rather than causes and conditions which enable infections, thus leading to the outcomes, which tend to lag behind new infections.

On March 1, Massachusetts loosened capacity restrictions for several industries and advanced to Step 2 of Phase III of the reopening plan. Since then, hospitalizations dropped by 20% and deaths dropped by 24%. The seven day average of new cases in long-term care facilities dropped by 53%. The positive test rate remains below 2% and has been for several weeks now. The seven day average of new cases is also down over this time by 7%. Sarah Finlaw, Press Secretary, Governor's Office, Press release

Our prediction

We predicted on Sat, 03/20/2021 that the reopening that would be allowed from Monday, March 23, 2021 coupled with the lack of compliance and lack of enforcement of the masking mandate would lead to an increase in COVID infections.

“The new regulations will allow indoor gatherings. Although people are encouraged to continue distancing and masking, there is no enforcement. These conditions are almost guaranteed to lead to more infections, hospitalizations, and deaths. Based on the CDC analysis of past patterns, we can anticipate that in about 20+ days, there will be an increase in infections; this will show as a higher proportion of positive tests on or about the 10th or 11th of April. We can also expect an increase of hospitalizations in 40+ days from March 22, on or about May 2, and an increase in deaths from May 2 through the 23rd of May.” Are We Safe Now? March 20, 2021

Controlling a system is difficult, and depends on using current information to determine how to act; delays make it harder to control the outcome. COVID spreads silently and rapidly, we have seen repeatedly that a small number of cases can quickly lead to an exponential increase of cases. Thus, it is crucial to monitor early indicators and to act rapidly based on data, not hopes. It is remarkable that the ongoing success of restricting the size of gatherings was used as the basis for loosening the restrictions. We argue that the restrictions should have been kept in place to drive the prevalence of COVID down much further.

Michael Siegel, MD, MPH, Professor, Department of Community Health Sciences, Boston University School of Public Health, is the public health advisor to the Stop Bullying Coalition. After reviewing our findings, he said:

“The numbers speak for themselves. It doesn’t require any rocket math to figure out that the governor’s policy had an impact on the case counts. It does make a case for a different policy, especially while we race to try to get everyone vaccinated. The loss of the J&J vaccine only makes things more urgent and only makes it more tragic that the governor opened everything up too early.”

Conclusion

We find that each variable we have tracked shows an increase in measures of COVID, in Essex County and in the Commonwealth, over the period from March 16, before the reopening, through to the latest report on April 14. Alas, we were correct, we wish we had been proven wrong. We can’t control the weather, but we can take steps to deal with hot or cold weather by controlling the temperature in our homes. We can take steps to control COVID by denying it the chance to find new people to infect. It takes smart policy and public cooperation.

Tracking COVID

	3/9	3/16	3/24	3/31	4/7	4/14
Essex County
14-day % positivity	2.55	2.55	2.93	3.32	3.56	3.55
14-day incidence	20.3	19.5	22.8	25.9	28.1	29.5
14-day case count	2263	2175	2544	2894	3132	3291
Commonwealth
14-day % positivity	1.83	1.83	2.01	2.36	2.54	2.48
14-day incidence	20.3	19.5	21.5	25.6	28.1	27.4
14-day case count	19791	19036	20975	24984	24379	26717

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Method

We can understand the dynamics of COVID by picturing the system consisting of the virus, the social environment, and the several variables that can influence the ability of the virus to transmit: masking, distancing, hygiene (personal and high-touch surfaces), indoor gathering sizes & frequency, personal and group identity, politics, local community organization, actions and influence of local leaders, public health mandates and interventions, influence of civic local, state, and national leaders, and more.

What we have tried to do here is to see if we can measure the impact of the state leadership which has the power to publish and enforce mandates on behavior that can, directly or indirectly, affect the rate at which COVID spreads and the various outcomes, such as infections, hospitalizations, and deaths.

We have chosen the changes in stages mandated by the Governor, i.e., “opening, closing, reopening” that will impact the number of people that can engage in activities known to enable transmission.

There are several measures that are published by state and federal agencies, including percent positivity, rate of incidence, case count, hospitalizations, and deaths. We have collected a time series for positivity, incidence, and case count for the state and for Essex county.

The independent variable would be the change in the stage, i.e., “reopening” and the dependent variables would be positivity, incidence, and case count as measures of the spread of COVID.

We have predicted that “reopening” would lead to an increase in the spread of COVID, and base this hypothesis on a study establishing such a connection. Research published on March 12 by the Centers for Disease Control and Prevention (CDC) in the Morbidity and Mortality Weekly Report (MMWR) has found that restaurant dining leads to an increase in infections; wearing masks reduces infections. That study found an increase in measures of infection with a lag of 20 days after restrictions on gathering were reduced or eliminated.

The Governor allowed an increase in the type and size of indoor gatherings from March 22, 2021. The data we have measures the dependent variables at weekly intervals, taking an average of the preceding two weeks. Each of the variables shows a rise in infection from before the reopening until the latest data on April 14, 2021.

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Data sources for Essex

March 18: COVID-19 Interactive Data Dashboard, data from 17-18 March, 2021; Count and Rate of Confirmed COVID-19 Cases and Tests Performed in MA by County; April 7: 3/21-4/3; https://www.mass.gov/doc/county-level-positivity-rates-april-7-2021/download

Provisional COVID-19 Death Counts in the United States by County; Data Provided by National Center for Health Statistics; Provisional count of deaths involving coronavirus disease 2019 (COVID-19) by United States county. Total at 4/14/2021 https://data.cdc.gov/NCHS/Provisional-COVID-19-Death-Counts-in-the-Unit…

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Data sources for Massachusetts

Count and Rate of Confirmed COVID-19 Cases and Tests Performed in MA by County; April 7: 3/21-4/3; https://www.mass.gov/doc/county-level-positivity-rates-april-7-2021/download

COVID-19 Raw Data, March 18, 14-day positivity https://www.mass.gov/info-details/archive-of-covid-19-cases-in-massachusetts#march-2021-

Empty slots in the table represent data which we could not find. Some of the reported data were extrapolated from graphs, other data was found in tables.

Archive of COVID-19 Weekly Public Health Reports; Data, weekly/biweekly, by city or town: https://www.mass.gov/info-details/archive-of-covid-19-weekly-public-health-reports

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Note on Count and Rate data

From Count and Rate of Confirmed COVID-19 Cases and Tests Performed in MA by County; April 7: 3/21-4/3

Data are current as of 11:59pm on 04/13/2021; 1Number of new cases occurring over the current two-week period (3/28/2021 – 4/10/2021) compared to the previous two-week period (3/21/2021 – 4/03/2021). Higher=number of new cases in the current two-week period higher than the number of new cases during the last two-week period. Lower=number of new cases in the current two-week period lower than number of new cases during the last two-week period. No change=number of new cases in current two-week period is equal to the number of new cases during the last two-week period. 2Change in percent positivity compared to the previous week’s (4/7/2021) report. No Change= <0.10% difference in the percent positivity. 3Address information for these cases is currently being obtained. DPH calculates rates per 100,000 population using denominators estimated by the University of Massachusetts Donahue Institute using a modified Hamilton-Perry model (Strate S, et al. Small Area Population Estimates for 2011 through 2020, report, Oct 2016.) Please note: Data for these tables are based on information available in the DPH surveillance database at a single point in time. Case counts for specific cities and towns change throughout the day as data cleaning occurs (removal of duplicate reports within the system) and new demographic information (assigning cases to their city or town of residence) is obtained.

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