When six counties announced last week that they are extending stay-home orders through the end of May, they also unveiled benchmarks they will use to determine when they can safely reopen the region.
An early analysis of those markers shows that while the Bay Area has made impressive progress in curtailing its outbreak — the reward reaped from millions of residents obediently sheltering in place for more than six weeks — the resources needed to further loosen restrictions and let people start returning to work and school are still largely lacking.
Case counts and hospitalization reports, two key gauges of the status of the outbreak, have either stabilized or are starting to decline. That means counties are starting to slow or even stop the spread of the virus.
But testing in all six counties is far below the goals set for the region — in some places it needs to increase seven-fold to meet targets. Most of the counties do not yet have a strong enough contact tracing program to effectively prevent future outbreaks. And most, if not all, do not have a large enough stockpile of protective equipment to safeguard health care workers if the number of patients rises.
Without those key resources in place, the region can’t lift shelter-in-place orders, say public health and infectious disease experts.
“We’ve been very fortunate here in California and the Bay Area because of sheltering in place. It could have been a disaster,” said Stephen Shortell, former dean of UC Berkeley’s School of Public Health. “Now we have this breathing room to give time and energy to how best to reopen — and that’s going to be on the supply side and the capability to keep us all safe once reopening begins.”
In extending the shelter-in-place orders for six counties — Alameda, Contra Costa, Marin, San Francisco, San Mateo and Santa Clara — the health officers eased some restrictions. Starting Monday, construction can resume, and outdoor-only businesses such as plant nurseries and gardening services can reopen. Some outdoor recreation areas can reopen, too, including golf courses and skate parks.
Public health officers said it’s possible they will loosen further restrictions before the end of the month. On Friday, Gov. Gavin Newsom said at a briefing that the state could be “many days, not weeks” from lifting some shelter-in-place directives.
But those decisions depend on state and regional metrics moving in the right directions, and much of that progress is in the hands of public health authorities — to increase testing capacity, for example, and to hire workers to do labor-intensive contact tracing.
“The effects of these new activities we’re allowing won’t be seen for a couple of weeks — that’s one reason we wanted these indicators, so we could monitor them,” said Dr. Erica Pan, the Alameda County health officer. “If we feel like things are better in a couple weeks, there’s a possibility we could relax some more.”
Public health officials said they hope to have a Bay Area-wide online “dashboard” to mark progress on each of the indicators soon. That would allow residents to monitor the progress in their communities and across the region. For now, it can be difficult to find much of the data, and the way it’s reported often varies widely from county to county.
The Chronicle analyzed the available data and requested further information that wasn’t online from all six county public health departments. Though some data was not provided, a fairly clear snapshot of the progress so far became apparent.
Case counts and hospital numbers: Public health officials want new cases reported and the number of people hospitalized with COVID-19 to stay flat, or decrease, every day for at least a 14-day period. All six counties are hitting those targets.
Across the six-county region, the number of new cases can vary widely from day to day — sometimes that’s due to a sudden increase in testing capacity, for example if a new clinic opens, and sometimes it can be traced to a specific cluster of cases, such as an outbreak at a homeless shelter or nursing home. But, over the past two weeks, the cases have been roughly flat or on a gentle decline.
Hospital counts don’t tend to fluctuate as much. Santa Clara County, which has the most cases in the Bay Area, has seen a consistent decrease in hospitalizations for COVID-19 patients. San Francisco reported a small rise at the end of April, but only by a few patients.
“We’re definitely seeing the flattening of the curve, we’re leveling off,” said Shannon Bennett, chief of science with the California Academy of Sciences. “We’re maybe going to start surfing down the other side. That’s a big cause for celebration. It does not mean we all run out and say, ‘It’s working, we can stop.’ It’s quite the opposite: We stay the course.”
Public health officials noted that case counts may increase over the next few weeks as testing improves. Indeed, Bay Area cases have climbed at times when new testing facilities opened. But eventually the numbers should stabilize again.
Hospital capacity: One of the primary goals of sheltering in place has been protecting the regional health care system and keeping hospitals from being overwhelmed with seriously ill patients. Therefore, an important marker of whether it’s safe to reopen is hospital capacity: specifically, the percentage of total beds that are occupied by COVID-19 patients.
Public health officials want to keep that occupancy rate below 50%. Not all of the counties report hospital capacity data on their coronavirus websites, but when asked directly, health officers said they all are meeting the occupancy goal.
In fact, among the counties that report hospital capacity data online, COVID-19 patients have made up only about 10% to 30% of hospitalizations, and the ratio has been going down.
Testing: The Bay Area has set an ambitious target for testing: 200 tests a day for every 100,000 residents. That number is higher than what Newsom has said is needed to reopen the state, which works out to about 150 tests per 100,000 residents.
But the Bay Area health officers have been more aggressive in their coronavirus response than many other parts of California. The region was the first in the country to issue shelter-at-home orders, three days before Newsom locked down the entire state.
So far, though, none of the six counties are close to meeting that 200-per-day goal. San Francisco is the closest, conducting about 100 tests each day. Alameda and Contra Costa counties are only doing about 30 tests per day. In both those counties, the health officers said the problem lies partly in a lack of resources, such as access to testing kits and other supplies, that are out of their hands.
But the counties also need to improve testing distribution within their communities, several health officers have said. They noted that some nursing homes and hospitals report not being able to test everyone who needs it, while some community clinics have more tests than people.
“It feels like we have a much larger capacity than what is being tapped,” said Pan, the Alameda County health officer. “We need to match the resources to where they’re needed.”
Contact tracing: Infectious disease experts say that even more important than testing may be contact tracing — the work of investigating every reported case of the coronavirus, identifying anyone in close contact who may be at risk of infection, and making sure all of those people are isolated or quarantined to prevent further spread of illness.
Contact tracing is critical to preventing another outbreak. But it requires an army of trained workers, plus resources such as housing to help people stay isolated if they can’t do so at home.
The six counties announced a “90-90-90-90” target for contact tracing: They must reach 90% of all newly diagnosed COVID-19 patients; they must make sure that 90% of those patients are able to safely isolate; they must reach 90% of the patient’s close contacts; and they must make sure that 90% of those contacts go into quarantine for two weeks.
It’s a difficult metric to track. Some counties are still figuring out how many workers they’ll need to successfully meet the goal. Other counties say they believe they’ve hired enough staff to do appropriate contact tracing now, but they will likely need to expand those efforts once shelter-in-place restrictions are lifted.
None of the counties report the status of this indicator on their coronavirus websites.
“Before this pandemic, we had about a dozen staff” doing contact tracing, said Dr. Chris Farnitano, the Contra Costa County health officer, during a town hall meeting Thursday. “Those are very, very small numbers. We’ve scaled that up to over 80 staff. But we need to scale up even more.”
Personal protective equipment: The final metric identified by the six counties is also the most challenging to track, and may still be up for debate: All hospitals, outpatient medical clinics, skilled nursing facilities and first responders must have a 30-day supply of personal protective equipment, including face masks, gloves and gowns.
Most of the counties are in the process of collecting that information from their hospitals and other facilities, but they are doubtful that every place has enough equipment at this time. In San Francisco, public health officials said they aren’t convinced that a 30-day supply is necessary — two weeks may be plenty, as long as the supply chain for ordering more equipment is reliable.
None of the counties report protective equipment data on their websites.
County officials are “still getting requests for PPE” from hospitals and other facilities, which means the usual supply chains aren’t meeting demand, said Farnitano. He added that the county is collecting data about how much equipment the facilities have on hand, but “we don’t think we’re meeting the PPE goal.”