Experts hopeful curve will stay flat
People are using masks, staying home, sanitizing
First came Wisconsin’s in-person election. Then it was protests over Gov. Tony Evers’ stay-at-home order. In midMay, a sudden court order opened the state. And, in the weeks since, there have been widespread marches against police brutality.
Coming amid the COVID-19 pandemic, each twist prompted concern among public health officials that a spike in cases would soon surface.
But to date, none appear to have led to a surge in the numbers tracking the disease’s spread. Rather, key indicators of COVID-19 — the percentage of people testing positive and the number of people being hospitalized with coronavirus — have continued to tick down in Wisconsin in recent weeks.
Some experts suggest these events, as much as they were highlighted in news accounts and across social media, do not appear to be as major of a driver of the disease as the behavior of individuals in everyday activities.
“This is just a sliver of the nearly 6 million people in Wisconsin,” said Patrick Remington, an epidemiologist and a professor of population health sciences at the University of WisconsinMadison. “These were highly visible and they could be high risk, but in reality, these were isolated events.”
For all the people protesting, voting or going out to bars right after the state Supreme Court’s ruling, many more people were going about their ordinary lives — but likely doing it differently than four months ago.
More people are clearly staying home, staying apart, wearing masks and sanitizing their hands. And though data is lacking, it appears that people are staying home more often if they are sick and making extra efforts to protect loved ones who are older or have health
problems, those most at risk of dying from COVID-19, according to experts.
Another factor that may be helping Wisconsin: the state’s temperate summer is making it easy to be outside, but is not yet hot enough to require air conditioning.
Residents in sweltering southern states are spending more time indoors and experts suggest air conditioning may be one of the factors behind the rise in cases there, as recirculated air can spread the virus.
But even as experts suggest what might be behind Wisconsin’s current encouraging numbers, they caution this is not a time to forget protective measures. They also say there is much they don’t know about the disease and lack data that would provide the best picture of the COVID-19.
“It is really hard to isolate one thing when so many things are going,” said Ajay Sethi, an epidemiologist and associate professor of population health sciences at the University of WisconsinMadison.
A key difference Sethi sees from earlier this year when COVID-19 grew explosively in Wisconsin: Public knowledge.
“We are not in a state of naivete like we were in January,” he said. “Our ignorance was a big contributing factor and we don’t have that ignorance anymore.”
Wisconsin in COVID spotlight
Wisconsin has effectively been a pandemic test tube, with events unfolding here that few — if any — other states experienced.
In April, the state Supreme Court cleared the way, in a last-minute decision, for an in-person election to proceed. The result was crowded polling stations particularly in Milwaukee, Green Bay and some other cities.
Many predicted a COVID-19 spike was inevitable, even though precautions were taken by voters and poll workers. None came — at least not one big enough to push up overall numbers.
There were reports of cases of COVID-19 that may have resulted from voting, and at least one study detected an effect from the in-person election, though some experts suggested other factors may have been at play.
On May 13, the Supreme Court struck down Evers’ stay-home order, allowing bars and restaurants to open for sitdown service that night. Importantly, though, the state’s biggest cities, Milwaukee and Madison, did not allow such businesses to open and wouldn’t for several weeks. Even today, capacity is limited.
After the court order, pictures of people hoisting beers in bars pingponged around social media, leading many to conclude Wisconsin was in wide-open party mode. But cellphone data from before and after the court ruling revealed a more complex story.
It showed the people in Wisconsin, as in other states, had already begun to move around by mid-April, even with stay-at-home orders in place. There was an uptick in movement after the midMay order but it was more of a continuation of a pattern than a spike.
More important was if people were cautious as they moved around more. People traveled more but the case numbers didn’t spike, suggesting to experts that people were embracing the precautions.
Experts say both voting and abruptly opening bars was unwise and likely led to some spread of the disease, but the effect may have been dulled by people being careful.
That brings us to the two waves of protests.
The first ones were against Evers’ orders and occurred in late April and early May. There were relatively few of them, but they drew much publicity as they were the first public gatherings in weeks. Interestingly, Sethi noted, while most did not wear masks, some protesters did.
“There is a lot of nuance to what people do, feel and believe,” he said. “You can oppose something and still worry about getting the disease.”
The larger, more widespread protest gatherings started in late May, after the death of George Floyd at the hands of police officers in Minneapolis. These marches continue, with thousands taking to the streets in state’s biggest cities but also smaller communities.
At these marches, most of the participants are wearing masks, but the size of the marches has some experts concerned.
“We cannot deny such an impact because of people on the street in public, standing close and shouting out and not wearing masks. That is ideal to spread the virus,” said Song Gao, assistant professor at the UW-Madison Geospatial Data Science Lab.
Other experts say there are reasons to think there won’t be an outbreak. The marches and protests are outdoors, a lower-risk environment for the spread of respiratory diseases such as COVID-19.
Most importantly, the number of people protesting pales compared to the state’s overall population.
“For every one protesting, there are three people going out for pizza,” Sethi said. “These (events) are not helpful and there is risk associated. The relative risk is high but the absolute risk is low.”
Positive data, work to be done
Wisconsin’s COVID-19 numbers have been trending in a positive direction in recent weeks.
Among the encouraging news:
As of Wednesday, 247 currently hospitalized patients in Wisconsin had tested positive for the coronavirus. That was down from more than 400 patients at the beginning of June.
The percentage of people testing positive for COVID continues to remain low, hovering about 3% in recent weeks. That’s down from about 9% in early May.
Deaths from COVID-19, which topped 700 this week, continue to fluctuate slightly, but the trend has been downward in recent weeks after a resurgence earlier this month.
In a call with reporters Wednesday, state health officials were cautiously optimistic.
“We’re not done until we’re highly confident we have this contained,” said Jon Meiman of the state Department of Health Services. “While the trends are encouraging, we still have a lot more work to do.”
Amanda Simanek, an epidemiologist at UW-Milwaukee’s Zilber School of Public Health, would like to see more metrics, such as how many cases don’t have a known source of infection — which states like Oregon are reporting. That indicates an infection may have broken out of one network, such as a meatpacking plant, and spread into the wider community, she said.
Under the safer-at-home order, it was easier for contact tracers to determine a source of infection because people probably had few daily interactions, Simanek said. As people open up their social circles, tracing will become more difficult.
Simanek said people’s efforts to socially distance over the past four months bought crucial time for doctors and scientists to focus on hiring contact tracers, get protective equipment, expand the number of labs doing COVID-19 testing and find more effective treatments.
“If we had let it rip through our state or country in the meantime, think of all those people who would have gotten (the disease) without the benefit of that,” Simanek said. “If the public health measures we enact work, it’ll seem like they weren’t necessary in the first place. And that’s honestly the best-case scenario.”
Oguzhan Alagoz, a professor of industrial engineering and infectious disease modeling expert at the UW-Madison, said his work shows social distancing adherence plays a major factor in the spread of coronavirus.
Without social distancing, he estimates that each infected person can, in turn, infect another three to four people — more contagious than seasonal influenza, but less than measles.
But if 70% of people adhere to social distancing guidelines, that number drops closer to one, he said. If 80% of people follow social distancing, Alagoz’s model estimates, that number drops to less than one, which means the disease will eventually die out.
“Me and my family are also tired of being careful,” Alagoz said. “But unfortunately we cannot get super comfortable . ... People should still be careful. Wearing masks, I think, is important, especially indoors.”
Infectious diseases like COVID-19 are particularly hard to predict due to the randomness of human behavior — for example, no model could have predicted that the country would erupt into protest, he said.
Because of the exponential nature of infectious disease, “if one or two people at the source are more careful or less careful, everything changes in the dynamics.”
Danger of comparing states
Much is being made about how one state is faring compared to another. Minnesota has had nearly double the deaths of Wisconsin despite a long stayhome order, prompting some officials to ask why.
Many are also pointing to states such as Arizona and Florida, which have seen a sharp rise in cases, suggesting it is because of stay-home orders being lifted too quickly.
That may be, the experts said, but they cautioned against coming to overly simplistic conclusions.
It is difficult, if not impossible, to compare states without knowing more about how they are testing for COVID-19, the robustness of their contact tracing and the speed with which people who test positive are being isolated.
Other factors making comparisons difficult are differences in demographics and disease progression, according to Nasia Safdar, an infectious disease doctor and professor at UWMadison.
“It’s all very local context-driven,” Safdar said. “Each state will have its own wave, its own peak and its own way that the pandemic moves through it. I don’t think we fully understand all the reasons why that is the case.”
Sethi, also from UW-Madison, said when comparing there is a risk of “cherry-picking” a state with numbers that fit a narrative or world view.
“It is not anything covert, it is just natural,” he said, “but it is not particularly scientific.”
All the experts advised a careful approach. Sethi said he doesn’t expect a new wave of exponential growth, not without some kind of warning in the data first.
But he and others are looking to fall and the holidays, when air travel may increase and more people gather in closer quarters to celebrate.
Safdar said it is likely that people will have to keep up social distancing for the “foreseeable future,” until there is an effective vaccine.
Simanek, who helps run a Facebook group called Dear Pandemic along with a group of experts in epidemiology, nursing, and health economics and policy from across the country, is encouraging people to remember the acronym SMART — Space, Mask, Air (stay outdoors), Restrict (keep groups small) and Time (keep visits short).
“For the rest of the summer, we’re going to have to navigate the choices we make and who we interact with,” Simanek said.
As the disease progresses, Simanek called on officials to further expand testing, especially before schools open in the fall.
“We may need more public health campaigns encouraging people to get tested, making sure that testing is free and that we are focusing on communities that typically have poor access to health care,” Simanek said.
Remington said the state has confirmed nearly 25,000 cases. That is surely an undercount of the actual number of people who have had COVID-19. If it is really 100,000 or 500,000, it means more than 5 million people have not had COVID-19, he said. And it is not clear how much immunity those who have it carry.
“So every time if we go back to business as usual, we’ll go back to the beginning and the curve will repeat itself,” he said.