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As Utah’s coronavirus case counts soar and hospitals warn that rationing care is all but inevitable, health experts say that state officials for weeks have rejected their recommendations for more severe restrictions to prevent further spread.
“Given the trajectory we’re on, we need — at a minimum — a two-week stay-at-home order to interrupt this transmission,” said Dr. Eddie Stenehjem, an infectious disease physician with Intermountain Healthcare.
Utah is now averaging more than 2,000 new cases a day, with hospitalizations for COVID-19 obliterating previous records, just two weeks after hospital officials warned that intensive care units may have to turn out the sickest patients in the near future.
And with four weeks of evidence, it appears the state’s new “transmission index,” which triggered mask mandates and group limits in most counties, has not worked.
“We’ve had enough time since the index was proposed to see improvements in transmission, if there were going to be significant improvements,” said Dr. Brandon Webb, an Intermountain infectious disease specialist. “And we’re simply not seeing any.”
Infectious disease experts have for about two weeks called on state officials to ramp up restrictions, especially on businesses like bars, gyms and theaters, said Dr. Andy Pavia, chief of pediatric infectious disease at University of Utah Hospital, who has served on various state groups in Utah’s coronavirus response.
But those recommendations stalled amid objections from political leaders, Pavia said. In fact, the state’s new guidelines, launched in October, eliminated previous restrictions that required gyms and pools to close, and bars and restaurants to suspend dine-in service, at the highest levels of infection.
Asked whether medical experts supported throwing out those rules as they advised Gov. Gary Herbert and other state officials who developed the new guidelines, Pavia said: “Absolutely not.”
“The removal of those restrictions came entirely out of the political levels” of the state’s Unified Command over the coronavirus response, Pavia said. "We weren’t really asked about it, specifically — so we assumed they would remain the same.
“I don’t think there was any attempt," Pavia said, "to assemble people with a medical and public health background” when deciding to remove specific business regulations.
‘It’s in our homes’
Leaders in the state’s pandemic response contend that the viral spread isn’t happening in public settings. They have blamed social and family gatherings for the current surge in infections.
Lt. Gov. and Gov.-elect Spencer Cox has pointed to data showing household and social contacts were behind nearly half the new cases in late October.
“It’s really easy to enforce social distancing in a business. It’s easy to enforce mask-wearing in our schools,” Cox told reporters this past week. “We see very little spread inside our schools. Where we see the spread is in the places where we can’t enforce that and nobody can — it’s in our homes.”
Utah Senate President Stuart Adams has also said he interprets the transmission data to show that business restrictions wouldn’t make a major dent in the case counts.
“If the data shows us that is productive, then that is something we ought to look at,” the Layton Republican said. “... If we’ve misinterpreted the data, let them help us with the data. But right now, it appears that social gatherings are the real challenge.”
But state data shows a rising number of cases where contact tracers couldn’t identify the source of transmission, said Keegan McCaffrey, an epidemiologist for the Utah Department of Health.
Even if the data showed more conclusively that transmission occurred overwhelmingly in homes and among friends, McCaffrey said, “each case has to get introduced to a household or a social group somehow. … That had to come from outside.”
By stopping transmission in public places, where spread is easier to prevent, Utah could limit the “amplification” of spread that occurs once someone takes it home and infects the family, Pavia said.
“We can’t say it’s ‘overwhelmingly’ [spread at home] because we have fairly limited detailed data," Pavia said, “and I think that’s being used largely as a straw man to avoid doing anything that impacts the business community.”
He noted, for example, that Herbert allowed restrictions on informal gatherings, limiting them to 10 people if transmission levels are “high” or 25 if levels are “moderate.” But there is no size limit on large gatherings that tend to be revenue-generating, like movies, entertainment and sports.
“It makes no sense," Pavia said, “that a sporting event or a dance or a theatrical performance can have large-scale gatherings if individuals have to keep below 10.”
Derek Miller, president and CEO of the Salt Lake Chamber, warned that imposing another round of severe business restrictions could devastate an economy already rattled by the pandemic.
“Anything that we do ought to be data driven,” he said. “Until we have data that tells us we ought to place additional restrictions on businesses ... I don’t see how it would be worth risking people losing their jobs and their ability to take care of their family.”
There is, however, evidence that certain, targeted business closures, accompanied by masking and social distancing, can drastically slow the spread of the coronavirus.
In Arizona, new COVID-19 cases were peaking in late June and early July at rates almost as high as Utah’s current counts. Arizona implemented rigid prevention measures, closing bars, gyms, pools and movie theaters, and limiting public events to 50 people.
As cases dropped precipitously, national health officials lauded the plan. And those businesses now may reopen at reduced capacities, according to a county-by-county rating system similar to Utah’s new transmission index.
But the standards — case rates and percentage of tests that are positive — are tougher in Arizona than they are under the Utah guidelines, which don’t require businesses to shut down.
To stay out of Arizona’s “high” transmission category, where bars, gyms and theaters have to close, a county can’t exceed 100 new cases per 100,000 residents for a week. That’s a far lower case rate than the level set in Utah that triggers only a mask mandate and limits on informal gatherings.
And in Arizona, no more than 10% of tests may come back positive for a county to avoid the most severe restrictions; in Utah, transmission is deemed “high” only if the percentage of positivity exceeds 13%.
The rules Arizona businesses must follow once they reopen also are far stricter than the distancing requirements under Utah’s plan. At Arizona’s “moderate” level — which is triggered by case rates that in Utah’s plan are defined as “low” — restaurants still have to limit guests to 50% of capacity and bars still aren’t allowed to open at all.
In Utah, 6-foot distancing is merely “strongly recommended” in restaurants and bars at the “moderate” level, and the capacity restriction in bars is 75% — more crowded than any affected business is allowed to be in Arizona right now, even at the lowest restriction levels.
For the past week, Utah has reported more than 450 new cases per 100,000 residents. On June 29, when Arizona announced its new restrictions, it had reported just over 400 new cases per 100,000 people that week.
This past week, three months after Arizona began allowing affected business to reopen, the state reported about a third that many cases.
Seeking a ‘social pause’
Intermountain doctors are drafting a proposal that would call for a “social pause” on all nonessential activities, but would leave it to policymakers to define what those are, Webb said.
The idea, he explained, would be to “give a chance for the life cycle of the virus to be interrupted and to decrease the out-of-control transmission rate."
Other medical experts have suggested specific business restrictions. Dr. Emily Spivak, an infectious disease physician at the University of Utah, has called for a two- or three-week stay-at-home order that would either close nonessential businesses or require modifications such as curbside pickup.
On Thursday, Spivak wrote that the record-shattering number of new COVID-19 cases was “ridiculous but expected” without leadership from Herbert and Cox.
“This is the biggest avoidable catastrophe of our lifetime, and we’re just watching,” she wrote on Twitter. “We must make policy NOW to protect our neighbors and hospitals.”
Webb noted that eating in restaurants is “one of the single greatest risk factors associated with getting COVID,” since it means sitting in an enclosed space without wearing a mask.
Pavia noted that businesses aren’t the only sources of public spread. While elementary and middle schools tend to have fewer cases, colleges and high schools have seen significant spread — especially because many of them insist on keeping sports and other activities going in person, even when they move classes online. And while places of worship “did a very good job in the spring," Pavia said, the message now seems to be that they can do whatever they want” without worrying about the virus.
It is possible that Herbert could follow the doctors' recommendations this time; after Friday brought a record number of coronavirus deaths, hospitalizations and new cases, Herbert wrote that in the coming days, he “will be announcing additional policies designed to address this ongoing surge.”
But asked Thursday about potential closures, Herbert said: “We really don’t want to close businesses. We think that has its own set of consequences.” He also praised businesses for enacting their own COVID-19 protocols, saying they’re already “motivated to keep their businesses safe, so their customers will come in and shop.”
Adams said he’s not dead set against additional restrictions but would prefer to focus on widespread testing.
“We’ve tried social pauses, and the challenge we’ve seen with them is they work for a week, they work for two weeks ... but when you come out of the social pause, you’re in the same spot you were before,” he said. “And the question is, how long can you social-pause after you’ve tried it?”
Adams said the state is gearing up for a “mammoth” effort to test all university and technical college students on a weekly basis. The first phases of the campaign will employ roughly a million rapid tests sent to Utah by the Trump administration, and Adams said national public health officials have pledged to supply as many kits as the state needs in coming months.
But Utah Rep. Suzanne Harrison, a physician by profession, said she’s concerned that state leaders aren’t paying enough attention to the advice of medical experts.
“I feel like having multiple press conferences where we ask pretty please for people to do the right thing is clearly not working,” Harrison, D-Draper, said. “Our front-line doctors and nurses are begging for meaningful action from state leaders. We need legislative leaders and Gov. Herbert to listen to the health experts and work to change this trajectory.”
House Speaker Brad Wilson, R-Kaysville, declined an interview for this article, saying he did not have time this past week in his schedule.
Even if Herbert’s measures include the restrictions medical experts are asking for, Pavia said, “my fear is we’ve waited too long.”
He noted that epidemiologists and physicians were asking for tougher measures when the state was reporting 1,200 to 1,300 new cases a day — just over half of what the state is counting now.
“It’s more clear that if we don’t act immediately to interrupt the cycle of transmission, hospital overflow is inevitable," Webb said, “and I fear that the community doesn’t fully recognize the full reach of impact that will have.”