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With a statewide spike in COVID-19 cases focused largely in Utah County, Gov. Gary Herbert is placing the county’s two largest cities, Provo and Orem, under tougher restrictions.

Herbert ordered those cities to go back to an “orange,” or moderate, level of restrictions at 11:59 p.m. on Wednesday.

“This is the first time that we’ve rolled backwards,” Herbert said during a Tuesday news conference. “Intervention is needed. A little pain now will be better than a lot of pain later.”

Within hours, the Utah County Health Department and County Commissioners Tanner Ainge and Nathan Ivie issued a joint public health order Tuesday night implementing a face mask mandate, beginning immediately and effective to Oct. 20.

The move comes as the Utah Department of Health announced that the state recorded 650 new cases of COVID-19 on Tuesday — and a seven-day average of 857 new positive test results per day, far exceeding July’s top weeklong average of 671 new daily cases. UDOH also reported two more deaths from COVID-19, bringing the overall death toll to 443.

State epidemiologist Dr. Angela Dunn said at the news conference that there has been “significant case growth in 12 of the state’s 13 regional health districts,” but pointed out that Utah County’s growth is 5.4 times that of the rest of the state.

Utah County is reporting a 23% positive test rate, Dunn added. “This indicates there is a lot of COVID spread in Utah County,” she said, explaining that the state is likely missing many cases because people aren’t getting tested.

Utah County recorded 291 new cases Tuesday. For the past seven days, it has averaged 58 new cases a day per 100,000 people, more than double the statewide average of 27.

In a letter addressing the spike, the Utah County leaders expressed concern about the case numbers, noting that if the current trajectory were to continue, “our health care system’s capacity could be at risk and the entire county may be put back into the Orange Level restrictions.”

The majority of residents and businesses “have done a great job of voluntarily complying with the guidelines and implementing changes to their lifestyle and business practices — often at great costs," the letter states. But it called on residents to continue following the state’s guidelines and to follow the new guidance on face masks in public settings.

“It takes all of us doing our part to get through this — hopefully resulting in a return to normalcy as soon as possible," they said.

Provo Mayor Michelle Kaufusi, in a statement that she also tweeted, called Herbert’s order “disappointing,” but said that it “can and should serve as a community rallying cry to more vigilantly follow health guidelines so we can quickly move back to ‘yellow’ to protect our local economy from further damage.”

The “orange” restriction category urges a limit on the size of public gatherings, indoor and outdoor, to 20 people. The less-restrictive “yellow” category recommends gatherings of no more than 50 people indoors. In both categories, those limits can be exceeded if event organizers follow strict health and safety guidelines.

Kaufusi said she hoped the order “is not a cause of discouragement to our citizens and business owners, but rather becomes an incentive to show how effective we can be when we fight COVID-19 together.”

Brigham Young University, which has experienced the worst campus outbreak since fall term began, reported 1,014 cases as of Tuesday. Utah Valley University had not updated its case numbers in more than a week, but it made a joint statement with BYU officials warning students that “more dramatic action,” including campus closure, may occur if numbers do not improve in the next two weeks.

House Speaker Brad Wilson said he shared Herbert’s concern for the current spike in cases in Provo and Orem. Moving to “orange,” the Kaysville Republican said in a statement, “will have a real and negative impact on businesses in those cities and the families they support, which is all the more unfortunate because of how avoidable this spike was.”

According to the Utah County Health Department’s most recent data, updated last week, several smaller towns in Utah County — including American Fork, Saratoga Springs, Alpine, Highland, Cedar Hills, Lindon and Mapleton — have per-capita rates above 35 cases a day per 100,000 residents.

In fact, the rates in Lindon and Mapleton are higher than Orem’s. Herbert defended not putting those smaller towns at the “orange” restriction level, saying, “We’re hoping to do it in a way that cuts out the cancer, but doesn’t kill the patient.”

Herbert said officials have “tried to have a scalpel approach, instead of a shotgun approach,” but warned that if this move doesn’t bring down rates, he may consider moving all of Utah County to “orange.”

Though Herbert is the ultimate authority on raising or lowering the color-coded restrictions, he left Tuesday’s announcement to Rich Saunders, the executive director of the Utah Department of Health.

“We’re optimistic we’ll be able to get Provo and Orem back to ‘yellow’ very soon, and eventually to ‘green,’ ” Saunders said.

Under the order issued Tuesday, there is one exception to the “orange” group limits, Saunders said: The state will allow team sports, “but with no spectators.”

Since late August, the rate of new cases among patients ages 15 to 24 has more than tripled, from 98 new cases per day to 336 new cases per day as of Tuesday.

During the first week of September, the age group overtook 25- to 44-year-olds as Utah’s biggest contributor of new cases, despite comprising a far smaller portion of the state’s population.

The two new fatalities in Utah were identified as a Weber County woman and a Salt Lake County man. Both died in a hospital, and were between the ages of 65 and 84. Hospitalizations statewide were up significantly Tuesday, with 161 Utah patients concurrently admitted, UDOH reported.

On average, 136 patients have been receiving treatment in Utah hospitals each day for the past week — a number that has been rising but remains below the peak average of 211 patients hospitalized each day at the end of July.

Utah’s intensive care units were 61.9% occupied as of Tuesday, meeting the state’s goal of less than 85% occupancy. In total, 3,550 patients have been hospitalized in Utah for COVID-19, up 30 from Monday.

The rate of tests with positive results was at 13.9% on Tuesday, up from Monday’s previous record high of 13.6%. Dunn has said a 3% positivity rate would indicate the virus is under control.

Statewide, Utah’s rate of positive tests has been above 5% since May 25, according to UDOH data.

There were 6,908 new test results reported on Monday, above the weeklong average of 6,192 new tests per day. Testing demand had been rising late last week but dropped again on Monday and remains far below mid-July, when the state was reporting more than 7,000 new test results per day, on average.

The state had not updated its coronavirus “response scoreboard” for a week and a half, but some of the health measures are straying further from the goals set in Herbert’s latest “accountability” plan. The goals include keeping weeklong averages to fewer than 400 new cases per day — a limit Utah met in mid-August but surpassed again on Sept. 3 as cases among young adults exploded.

The state’s key metric under Herbert’s plan — a coronavirus death rate of less than 1% — stayed at 0.7% on Tuesday, possibly driven down by the large number of new cases among young and lower-risk patients.

Tuesday also marked a national milestone: Johns Hopkins University’s COVID-19 tracker reported the United States surpassed 200,000 deaths from the disease. As journalist Yashar Ali noted on Twitter, that’s equivalent to the entire population of Salt Lake City.

One move Herbert declined to make, for now, is a statewide order for residents to wear face masks. Both Salt Lake County Mayor Jenny Wilson, a Democrat, and state Sen. Deidre Henderson, the Republican candidate for lieutenant governor with current Lt. Gov. Spencer Cox, made calls Monday for a statewide mandate. Wilson wanted immediate action, while Henderson said a mandate would be needed if county-level leaders failed to act.

“A statewide [mask] mandate doesn’t make a lot of sense to me,” Herbert said. “I think it would be overkill to mandate mask-wearing statewide, in areas where it would do no good.”

Herbert also chastised Wilson for mounting “more of a political stunt,” by making her request in a letter that she released to news outlets, rather than calling the governor on the phone.

Wilson, through a spokeswoman, did not reply to Herbert’s “political stunt” comment — and referred back to Wilson’s Monday letter, in which she said “the governor should have already imposed a mask mandate throughout the state.”

In contrast to the “orange” restrictions in Provo and Orem, Herbert ordered Tuesday that Rich County, in far northern Utah, would move to the least-restrictive “green” category, also beginning at 11:59 p.m. Wednesday. Rich will become the 14th county, all in rural areas, to move to the “green” designation. All other parts of the state remain in the “yellow” category.

Brad Wilson, in his statement, also decried a statewide mask order. “Such a policy imposes a one-size-fits-all solution when a more targeted approach, led by local leaders whenever possible, is effective without forcing counties where cases are lower to operate under the heavy hand of government,” Wilson said.

Herbert stressed the “exhaustive” work state officials did over the weekend analyzing COVID-19 data. Forty officials were in the governor’s command center, Herbert said, and another 150 staffers and advisers gave input.

“Not every state is approaching this the same way,” Herbert said. “We haven’t been perfect in our approach, but we’ve had pretty darn good outcomes.”

Herbert pointed to Hawaii, which he said did better curbing the virus, but at the cost of the island state’s economy. “We’ve tried to have a balanced approach,” Herbert said, between Utahns' health and the economy.

Saunders praised the work of businesses and of ordinary Utahns in adjusting to the pandemic. “We’re learning to live with the virus, and that’s a good thing. We really rely on all of you to fight this enemy,” Saunders said.

The governor said he understands, "perhaps better than anybody, that life under COVID-19 is a stressful situation. People are scared about the virus.” Older residents, who are at higher risk for getting more sick from the virus, are very concerned, he said, while “young people … are probably taking it a little bit lackadaisical.”

Herbert added: “We all have the challenge of doing our part. It’s OK to get sick, but it’s not OK to put others at risk.”

- Salt Lake Tribune reporter Taylor Stevens contributed to this report