A PRIMER ON SOCIAL DISTANCING IN THE TIME OF COVID…

Written by our MCW Pediatric Residents: Dr. Michelle Hwang and Dr. Swathi Prasad.

We’ve all heard quite a bit of terminology about what cities, towns, counties and countries have asked of their citizens for the purpose of community safety. So we wanted to take some time to clarify what some of these terms might mean and what appropriate activities might be.

Let’s start with some definitions.

What is… Social Distancing:

• Deliberately increasing physical space between people and minimizing contact with people outside of your immediate household in order to avoid spreading a contagious disease. The CDC defines social distancing as it applies to COVID-19 as “remaining out of congregate settings, avoiding mass gatherings, and maintaining distance (approximately 6 feet or 2 meters) from others when possible.” For a detailed account of their definitions and guidance, click here. 
  • The evidence? First, data gathered from the 1918 Spanish Flu pandemic found that “cities that deployed multiple interventions at an early phase of the pandemic—such as closing schools and banning public gatherings—had significantly lower death rates.” You can see a chart and more info here. 
  • More recently? Experts say that “an early study, not yet peer reviewed, showing the different experience of peak coronavirus rates for two Chinese cities. The city of Guangzhou, which implemented disease control measures early into the outbreak, had significantly lower numbers of hospitalizations from COVID-19 on its peak day than the city of Wuhan, which put measures in place a month into the outbreak.”
  • What does this actually entail? A How to Guide for Social Distancing 
    • These guidelines are for individuals without symptoms.  If you are feeling sick click here for what to do. 

What is… Self Quarantine?

• The practice of separation of a people who have been exposed to a contagious disease (but not yet symptomatic) from others who have not been exposed in order to prevent the potential spread of disease. If you have a known exposure to COVID19, it is recommended to stay at home and restrict contact with other individuals for a 14 day period (as recommended by the CDC) to monitor for symptoms. This provides enough time for an individual to know whether or not they will become ill and contagious to other people. 
  • Who should practice self quarantine? 
    • If you have recently returned from traveling to a part of the country/world where COVID-19 is spreading rapidly 
    • If you have knowingly been exposed to an infected person 
  • What does self quarantine involve? 
    • Using standard hygiene and frequent handwashing
    • Not sharing things like towels, cups, and utensils 
    • Washing your own dishes and clothing
    • Staying at home and not having visitors 
    • Staying at least 6 feet away from other people in your household

What is… Mandatory Quarantine?

• This is referring to city-wide lockdowns that force people to stay in their homes and cut off all travel to and from an impacted area. This helps to separate and restrict the movement of people who were exposed to a contagious disease.
  • What does this actually look like?
    • In Wuhan, China, all residents were ordered to stay in their homes and all transit within and out of the city was shut down. 
    • In Italy, residents of cities were banned from travel within and out of the city without a permit.
    • In the US, six counties in San Francisco announced on March 16th a “shelter in place” order restricting all residents to their homes (with few exceptions including grocery stores, pharmacies, and care of vulnerable family members) until April 7th at the earliest. As of March 24 2020, the newest state to enact a similar “Stay home, stay safe” order which should last one month is the state of Wisconsin. By March 26th, Alaska and Hawaii will have issued orders mandating a 14 day quarantine for all visitors and residents arriving at state airports. Florida issued an executive order requiring anyone flying to Florida from New York, New Jersey, or Connecticut to self-isolate for 14 days upon arrival.
  • Who determines a mandatory quarantine in the US?
    • As usual, there is no standardization and decisions are split between federal, state, and local public health departments. The federal government also has the power to step in and overrule state and local governments’ quarantine decisions.
  • Is anyone else doing it?
    • YES. (Click here for constant updates.)
    • Though China’s was the first with 16 cities at the end of January, and more as time went on, close to one-third of the global population is now on a lockdown. As of March 24 2020, India had just declared a mandatory quarantine on its population of over 1.3 billion people. South African will go into a 21 day lockdown on March 26th. New Zealand is planning for a month, Saudi Arabia has locked down the capitol and two holy cities, and the UK prime minister reversed his previous declarations against a quarantine by implementing their own lockdown on the 23rd. Australia is slowly expanding it’s lockdown and closures plan, Jordan and Argentina are on strict indefinite lockdown, and the list goes on…

What is… Isolation?

• Separating people (or communities) who are known to be infected with a contagious illness away from people who are not infected in order to prevent the spread of contagious disease. Isolation may be voluntary, or compelled by governmental or public health authorities.  
  • Who should be in isolation? 
    • People who are confirmed to have COVID-19 
    • People who have been tested for COVID-19 while awaiting test results
    • People who feel sick with fever and respiratory symptoms (even if you did not get tested for COVID-19). Click here for tips if you feel sick. 
  • What does isolation involve? 
    • Staying at home if you have a mild illness. If you live with others, try to minimize your movements and avoid sharing utensils, dishes, food with those you live with. 
    • Staying at a hospital or care facility if you have severe illness. If this is the case, special personal protective equipment (PPE) will be used to care for these patients

What is… Flattening the curve?

• Refers to using protective practices to slow the rate of COVID-19 so hospitals have enough rooms, supplies, and doctors for the patients who need care.

• Why is this important? 
  • A large number of people becoming sick from COVID19 over a short period of time could overwhelm a hospital and result in shortages of hospital beds, equipment (such as ventilators) and doctors. This would ultimately mean making difficult choices between which patients get medical care (this has already happened in Italy). If instead, the disease spread at a lower rate (over the course of several months), then each day there would be fewer patients on average requiring medical attention. This would give hospitals a better chance of keeping up with adequate supplies, beds, and health care workers. 
  • Current projections of our ventilator capacity approximate under 175,000 ventilators available at hospitals or in the National Strategic Stockpile. With, as of March 25 2020, a total of 55,600 cases confirmed and a daily increase in 6-10,000 confirmed cases per day (and rising) over the past week, our confirmed cases (with severe to critical symptoms) will surpass our vent capacity within two weeks. Even more concerning, data from China states that “for every known case of infection, there could be up to 10 people with the virus that remain[ed] unidentified in the community”…which could make this timeline even shorter. 

Why does this all matter?

The Washington Post has a great simulation that gives a visual on why outbreaks like Coronavirus spread exponentially and how to “flatten the curve”. 

Here are the basics: The number of new cases of Coronavirus in the United States have begun to follow an exponential curve, with the number of cases doubling every 3 days. If this continues there will be about a hundred million cases in the United States by May. The spread can be slowed, however, by practicing “social distancing” and quarantines.

Let’s look at how different countries adopted this and their results.

China (Hubei): China is the most aggressive country to quarantine. Seems to be working.
In January, Wuhan became the epicenter of the COVID19 outbreak. In the attempts to slow the spread of Coronavirus, the Chinese Government imposed a mandatory quarantine on Wuhan’s 12 million residents. This lockdown was initiated quickly after about 30 deaths. The lockdown was then extended throughout Hubei Province (50 million people were locked in their homes). The lockdown continues and now most means of transportation have been shut down in Hubei. China continues to lead the world in the number of confirmed cases but has recently begun to slow the rate of infection. On March 19, China reported not a single new case of domestic transmission. 

Italy: Aggressive social distancing but too late, and large elderly population doesn’t help
Italy’s first identified case of community transmission of COVID19 was in mid February. Shortly after, Italy announced a lockdown affecting just 50,000 people who were prohibited from leaving “hotspot towns”. As cases grew to >2500 by March 4, Italy announced the closure of schools and universities nationally. Finally by March 8, with 5,900 confirmed cases, the government ordered a lockdown for 16 million people and closed museums and theatres across the country. And by the next day, March 9, with 7400 cases, the lockdown was extended to the rest of the country. By March 11, with nearly 12,500 cases, the government halted all commercial activity aside from supermarkets and pharmacies.

South Korea: Adopted aggressive testing and contact tracing/isolation. Working so far. 
South Korea identified its first COVID19 case on Jan 20. With only 30 new cases confirmed in the weeks following this President Moon Jae-in urged citizens to resume regular activities. However after a breakout in Daegu related to a religious sect in February, SK saw an exponential growth in infections. Recently however, SK appears to have greatly slowed its epidemic. Cases have gone down 90% from the peak. The government has dismissed the idea of lockdowns and though SK promotes social distancing there is no ban on mass gatherings, only recommendations. Rather than enforcing strict social distancing, SK has focused more on contact tracing, even retracing steps of diagnosed individuals using GPS phone tracking. They have focused extensively on isolating infected individuals (case isolation) and quarantining their contacts. Another part of SK’s success is an expansive and well-organized and aggressive testing program.

US: Social distancing but a delay in ramping up testing. Still waiting for our peak.
The United States had its first case of community transmission of COVID19 in California on Feb 28. In the first 2 weeks of March, schools and university closures became the new norm, workplaces went remote, and state and local governments banned large gatherings. Sports leagues suspended their seasons. What does the US government have to say about it now? On 3/16/2020, the White House announced new guidelines for the next two weeks, urging Americans to avoid gathering in groups of more than 10 people; to avoid discretionary travel, shopping trips, or social visits; and not to go out to restaurants or bars. 

UK: Trying to balance social distancing with practices that are sustainable for the people and economy in the long haul. 
UK has come under scrutiny as it seemed like the initial response of the country was to allow the infection to run its natural course and allow the population to develop “herd immunity”. They have been slow to adapt aggressive social distancing methods. The argument is that strict social distancing will be hard to sustain over time so it must be saved for when it is truly needed. Recently the UK came out with new guidance encouraging social distancing for all and the NHS in England is contacting particularly high risk individuals (age >70 and those with complex underlying health problems) with advice for more stringent measures. 

What can we learn from other countries?

• China seemed to slow its spread from adopting robust quarantine measures (and implementing them quickly). However, some have argued the sustainability and morality of such strict measures. 
• South Korea’s success seems to stem from aggressive testing measures. They created an effective test quickly following identification of their first case and used it widely. By testing and identifying infected individuals, they have been able to slow the spread by tracking down exposed individuals and individual quarantines. Through these measures they have had good success even without implementing strict social distancing. The US on the other hand did not quickly develop testing and we are still testing far less than these other countries due to lack of supplies.  
• Singapore, Hong Kong, Taiwan, South Korea, and China have all flattened their curves despite an initial explosion of cases. Gives us hope and something to emulate. 
• The UK’s slow response to implement social distancing reminds us that the consequences of strict social distancing and quarantines (including that to mental health and national economy) must be taken into account as projections continue to predict many more months of COVID-19 spread. 

How long will social distancing last for?

This is the tough part. Per expert models, if we are successful in “flattening the curve”, then we will both slow the spread of COVID19 so that it does not overwhelm the health-care system but also elongate the curve. We will end up stretching it out over a longer period of time (see graph above on flattening the curve). That means that all of our strict social distancing measures will have to be maintained until either a vaccine becomes available or transmission slows, probably a matter of months rather than weeks. Basically, socially distancing will have to continue indefinitely for now and we don’t know how long it will last for. To make matters worse, epidemiologists are predicting a second wave in the fall. As of March 24, 2020, President Trump is proposing reducing restrictions by Easter but…we’ll have to wait and see. 

For all you other questions including:
How do I Practice Social Distancing?
What to do if I feel sick?
What if I can’t afford to work?
Click here.

Written on March 24, 2020. Last updated March 25 by Dr. Michelle Hwang & Dr. Swathi Prasad. All sources hyperlinked within article.