To slow COVID-19 spread, California county turns to mitigation

In what is likely a harbinger of things to come as the number of COVID-19 cases rises across the country, Sacramento County announced Mar 9 that it is shifting its efforts to slow the spread of the virus from containment to community mitigation.

That means that people who've come into contact with someone who has the pandemic coronavirus will no longer have to quarantine themselves for 14 days, according to a county news release. The recommendation applies to members of the general public as well as to healthcare workers and first responders.

People who develop respiratory symptoms are urged to stay home and manage their symptoms with over-the-counter medications, unless difficulty breathing or lethargy develops, or symptoms improve and then get worse.

The county is also recommending that vulnerable populations, including older county residents and people with underlying health conditions or weakened immune systems, consider staying home and avoiding crowded social gatherings to prevent the disease.

In an interview with the Sacramento Bee, Peter Beilenson, MD, head of Sacramento County's Department of Health Services, said the move is an acknowledgement that the novel coronavirus is in the community, and that trying to contain it through quarantines and contact tracing is no longer feasible.

"Once you get a certain number of cases, it's hard to contact-trace back the way you tried originally," Beilenson told the paper. "So we move to mitigation, which is basically trying to mitigate the risk to those who are most at risk: the elderly and those with chronic underlying conditions."

California is where the initial US evacuees from Wuhan were quarantined, and where the first US case of COVID-19 community spread was identified. As of yesterday, the state had 157 positive cases, according to the California Department of Public Health, and more than 10,300 people are self-monitoring around the state. Sacramento County has 10 confirmed COVID-19 cases.

From containment to mitigation

With the number of COVID-19 infections steadily rising across the country and more cases expected nationwide, the discussion around containment versus mitigation is taking on new urgency. Some experts say that at this point, the coronavirus is likely in the community in many parts of the country, and containing it is no longer an option.

Therefore, the focus needs to be on measures at the population level that slow the rate at which people get infected and prevent the healthcare system from being overwhelmed.

"We certainly are past containment. We have to think about aggressive steps at mitigation," former Food and Drug Administration Commissioner Scott Gottlieb, MD, said in an interview with USA Today. "My concern now is we're not taking aggressive enough steps at mitigation to prevent a broader epidemic."

Gottlieb suggested that shutting down movie theaters and other places where you have a large number of people congregating indoors could be an option.

Tara Smith, PhD, a professor of epidemiology at Kent State University, says other affected communities will likely be looking at the mitigation approach.

"I suspect this is something we will see implemented in local communities in other affected communities in the coming days—at least, aspects of it," Smith said. "I think it will be important to emphasize social distancing whenever possible: avoiding large public gatherings, working from home if you're able."

But Smith also said she would encourage those who have a known exposure to a COVID-19 patient to self-quarantine if they are able, given the reports that individuals may be able to infect others very early in their infection, even before it causes symptoms. For example, a recent study by German scientists found that the novel coronavirus begins producing high viral loads that can be spread through breathing even before a person develops symptoms.

"I think we're past stopping the outbreak, but we can slow it," she said.

Too soon to give up on containment?

Jonathan Eisen, PhD, a professor in the department of medical microbiology & immunology at the University of California-Davis, said that while he's not opposed to mitigation measures, and understands that focusing on containment will stretch resources, he thinks it's too soon to give up on containment.

"I'm not convinced that the time is right to switch from containment to mitigation, especially when recommendations from the head of the WHO and other places say it's not an either/or, it's both," he said. "I think you can still use containment in some circumstances. Within the county, there may be pockets that containment will be useful for," he added, referring to quarantine and contract tracing.

But Eisen also said he thinks the county's mitigation plan should be much more aggressive, noting that it doesn't make any specific recommendations against large gatherings, and that the recommendations on schools that have had COVID-19 exposure and on telecommuting aren't strong enough.

The county news release say workplaces and businesses "may consider implementing telecommuting and teleconferencing for their employees, where appropriate and feasible," and that schools that have a COVID-19 exposure or case should be in contact with the local health department and County Office of Education about the appropriate next steps.

Elsewhere in California, Santa Clara County's public health department has issued a mandatory order requiring the cancellation of mass gatherings starting today, and Yolo County "strongly recommends" cancellation of non-essential large gatherings. In Seattle's King County, one of the US epicenters of COVID-19, public health officials are recommending that people consider postponing community events and large gatherings through the end of the month.

And today Washington Governor Jay Inslee announced restrictions on gatherings of more than 250 people in King, Shohomish, and Pierce counties.

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