Rising Inaction: COVID-19 cases

Rising Inaction The health department says the data does not support calls to suspend indoor dining. So what does that data suggest D.C. do to reverse the trend?

By Amanda Michelle Gomez

@AmanduhGomez “INCREASING TREND” reads a July 23 press release from the District’s health department. An accompanying line graph shows multiple red dots that represent peaks in new COVID-19 cases throughout the month of July.

That press release was the first time the Bowser administration acknowledged that the number of cases in D.C. was climbing again, after the city experienced weeks of declines and plateaus at the end of spring and into early summer. On July 24, a day after the press release went out, Mayor Muriel Bowser ordered anyone traveling into D.C. from “high-risk” states to self-quarantine for 14 days.

Three weeks later, little has changed. D.C. experienced another peak in cases on Aug. 3, when it recorded 83 positive test results, according to DC Health’s graph of community spread, which measures cases by symptom onset and excludes infections in congregate settings like nursing homes and homeless shelters. This is the highest peak in cases since May 28, when the city saw 90 new cases and was under a strict stay-athome order.

The community spread graph is updated daily, but the data in it trails the present by about a week and a half. As of Aug. 18, D.C. reported an average of 61 cases per day during the past week, yet the executive order related to travel is the last major action the administration has taken to reverse the trend.

COVID-19 cases started to slowly and steadily increase during Phase 2, when the Bowser administration relaxed more coronavirus-related restrictions and allowed select businesses to reopen indoor services at reduced capacity on June 22. On that day, D.C. recorded 37 cases per day, based on a seven-day rolling average. Despite calls to restrict riskier activities like indoor dining, Bowser has not rolled back any activities or suspended the operations of any businesses. The mayor says she’s following the advice of her health department, and DC Health Director Dr. LaQuandra Nesbitt says the coronavirus data does not indicate that she should recommend such action.

“I’m getting asked by the Council and I am getting asked in this room all the time, ‘When are you going to close indoor dining?’” Nesbitt said during a press conference on Aug. 18. “I can’t make the data tell me to tell you that 30 to 40 percent of my cases are related to it. That is just not the case.”

“We know indoor dining is high risk. We have people indoor dining in the District. I’m still seeing a higher proportion of my cases related to the workplace or travel, and not attributed to indoor dining,” Nesbitt continued.

Nesbitt declined to offer any more detailed information about workplace infections, but she did elaborate about travel. Of the 971 people who tested positive between July 31 and Aug. 13, Nesbitt said 102 people reported traveling while infectious and more than 70 percent of those people say they traveled by plane. Nesbitt also said 145 of the 971 people who tested positive reported attending a gathering of five or more people while infectious. About 90 percent of gatherings were under 50 people—they at least followed that part of the Phase 2 guidance—but more than 60 percent say people were not practicing social distancing at the event, be it a religious service, cookout, or party. A majority of the people who attended these events said at least part of their gathering occurred indoors. By comparison, Nesbitt said 5 to 8 percent of the new cases were connected to people eating at restaurants.

“You’ve heard Dr. Nesbitt talk about travel,” Bowser said later in the press conference. “That is why we continue to make reminders to people to not get complacent about their activities.”

Nesbitt’s insights are based on data gathered by her department’s contact tracers, a team of nearly 300 investigators who interview D.C. residents that test positive for COVID-19 along with individuals those residents come in close contact with. Contact-tracing data so far shows cases are not connected to one another, as a majority of sick people who answered an investigator’s question about whether they knew someone who tested positive said no. The data has limitations. Contact tracers completed interviews in roughly 70 percent of positive cases between June 16 and August 13, but they just started asking the same questions within the last two weeks. It’s unclear what questions were added, but Nesbitt suggested contact tracers recently started asking about indoor dining. DC Health is looking to further refine its contact-tracing program and is, for example, having staff conduct home visits with those who are unreachable or decline to complete their interviews.

The Aug. 18 presentation came after members of the D.C. Council questioned Nesbitt about what her department had learned from contact tracing and if that knowledge could prompt rollbacks of any kind to reduce cases. According to the Post, Nesbitt became frustrated with lawmakers’ line of questioning, saying, “Sometimes the tone and the tenor of these questions are completely insulting, as if we are not doing our level best to stem the tide.”

At-Large Councilmember Elissa Silverman says she sees weekly calls with DC Health as a way to provide oversight. She continues to call for more transparency around contact-tracing data, and suggests DC Health publish its findings on its online dashboard, as a few other states have. She’d like to see something like Louisiana’s public data, which includes a list of the settings where outbreaks are happening and how many cases are associated with those settings.

Silverman is also among those residents who thinks the city should suspend indoor dining again. She disagrees with the decision to reopen indoor dining rooms and gyms during Phase 2, given what epidemiologists are learning about the coronavirus. Since the start of the pandemic, the World Health Organization stressed that COVID-19 spreads through virus-laden droplets when a sick person talks or sneezes, and updated its guidance in early July to say that COVID-19 may also spread through respiratory droplets so small they linger in the air in confined indoor spaces.

“We know the risk is high,” Silverman says. She believes the decision to not suspend indoor dining speaks to how important restaurants are to the local economy and how influential the lobbying of the Restaurant Association of Metropolitan Washington is.

“We can take action as a government to prevent the spread,” says Silverman. “We can’t go into your house or your backyard, but we can say indoor dining is closed.”

In a Council call with the executive on Wednesday, the topic of restaurants came up again. Silverman wondered if the increase in cases among young people could be related to indoor dining. Nesbitt told her the data does not suggest this.

An analysis from the Center for American Progress found states in the Northeast better contained coronavirus transmission as compared to the rest of the country, including D.C., because lawmakers there made masks mandatory before lifting stay-at-home orders and waited to reopen indoor dining at restaurants and bars. Emily Gee, a health economist at the think tank who led the research, says the analysis does not suggest D.C. restrict all indoor services— just dining, because restaurants are prime vectors.

“Besides the fact that places like Michigan have traced huge outbreaks to bars and restaurants,” Gee says, “inherently, you can’t wear a mask the whole time you’re in a bar or restaurant if you’re dining or drinking. You need to pull down that mask.”

“There’s also a huge cost to being at this state where [transmission is] not quite low enough that we can even have public schools running,” she says.

Case counts do not tell the whole story. Hospitalizations related to COVID-19 have either been decreasing or plateauing during Phase 2, and the positivity rate has stayed below 5 percent.

“Overall, D.C. is doing relatively well as compared to other states, but has the opportunity to be even better,” says Joshua Sharfstein, the vice dean at the Johns Hopkins Bloomberg School of Public Health, who is advising mayors across the country on the coronavirus.

“The city is still at risk for a real increase,” he cautions.

So should the city close indoor dining? “It’s sort of a question if we want to push cases down enough to create a margin of safety ... It makes it safer to open schools,” says Sharfstein. “If you were able to get virus transmission lower, cases would go down, especially heading into the fall.”

The transmission rate has increased to an alarming level at two different points during Phase 2. The transmission rate, or the number of people a sick person is likely to infect, crept above 1 in late June and early July and again in late July and early August. A value above 1 means the virus is spreading and more cases are likely.

Throughout the pandemic, Bowser has repeatedly said she has the ability to reinstate restrictions if coronavirus data suggests D.C. reopened too quickly. “We see it as a valve going on and going off, so my expectation would be that the health department would consider some things that had to be turned off,” Bowser said during a June 5 press conference, where she announced the benchmarks the city needed to meet before moving to Phase 2.

During this press conference, the health department also released information on what in the coronavirus data could trigger reinstating restrictions. DC Health would possibly recommend an intervention if D.C. saw three days where new cases were greater than “Day Zero.” The department later determined “Day Zero” was June 15, when it recorded 45 cases. D.C. only recorded fewer than 45 cases on two days in July.

So far during Phase 2, the Bowser administration has taken two notable interventions. On July 22, the mayor made masks mandatory whenever someone leaves their residence, except in limited circumstances, and, two days later, made quarantine mandatory for select travelers. Enforcement remains a challenge. Officials generally let businesses and individuals enforce the mandates themselves. Nesbitt, for example, has not used her authority to order anyone to quarantine or isolate.

“What we are trying to do is educate people so they know what their risk is if they put themselves in that situation—that goes for dining, that goes for travel, and that goes for being in a group setting,” says John Falcicchio, Bowser’s chief of staff and deputy mayor for planning and economic development.

Dr. Amanda Castel of George Washington University’s Milken Institute School of Public Health can understand why D.C. has yet to reclose or restrict anything, as it is faring well within the context of what is going on nationally. From a public health perspective, Castel supports restricting riskier activities. She could also understand officials needing “strong evidence” from contact tracing to justify restrictions because of the political and economic realities.

“But they are doing other things, adding layers to what is already in place to see if that is making a difference,” she says, referring to the mask and travel orders, as well as the investment in the contact-tracing program.

Castel likens it to a smoldering fire. DC Health is not seeing any sparks that might prompt the city to tamp down the spread, and for now, there are no flames.