The University of Tennessee, Knoxville.
Stay-at-Home Measures and Effects on COVID-19 Cases in Knox County

A Policy Brief by the Howard H. Baker Jr. Center for Public Policy

in Partnership with the Coronavirus-19 Outbreak Response Experts (CORE-19)

April 8, 2020
Tennessee State Capitol and Flag
Using publicly available data from emerging research on COVID-19, this brief was written and reviewed by the Coronavirus-19 Outbreak Response Experts (CORE-19) at the University of Tennessee, Knoxville. It explains Tennessee's policy response to COVID-19 as it relates to mass gatherings and limiting business operations. 

Overview

COVID19 was first detected in the United States on January 21st, 2020 and has since spread across the entire nation. Because the virus spreads between individuals who are in close contact through respirator droplets produced when an infected person coughs, sneezes or talks, local, state, and the federal government have responded by developing policies designed to limit close and sustained contact between individuals.
The goal is to limit the opportunities for individuals to come in close and sustained contact to reduce
the spread of the virus.
This briefing has two purposes. First, it will describe the policy response in Tennessee as it relates to restrictions on mass gatherings and limiting business operations. While many other kinds of policies have been enacted during the pandemic to date, such as school closures, this briefing will not address them. Mass gatherings are defined as public or private events with a large number of people in attendance. Placing an upper limit (or maximum) on the number of people who can attend a mass gathering can help slow the spread of the virus by reducing the opportunity for an infected person to interact with a large number of people in a short time period. Policies designed to limit business operations can take several forms, such as restricting capacity or operating hours, but the most common form is business closures. Again, the goal is to limit the opportunities for individuals to come in close and sustained contact to reduce the spread of the virus.

Stay At Home Orders 

One policy that has gained increasing attention over the past several weeks are stay at home (SAH) orders. For the purposes of this briefing, SAH orders are considered a type of mass gathering restriction. SAH orders, which include safer at home or sheltering in place orders, place restrictions on the movement of individuals outside of their home. To be included in this briefing an order or guidance must explicitly instruct individuals to stay at home.
Under a SAH order individuals are allowed to leave their home to engage in what most state and local governments refer to as ‘essential activities’ that generally include shopping for necessities, including groceries, seeking medical attention, caring for a family member, or outdoor activity. There are also generally exemptions for individuals who work in what are referred to as essential businesses or essential infrastructure. These businesses must remain open during the pandemic due to their importance to public health, security, safety, etc. 
Many governments have referred to the essential infrastructure guidelines developed by the Department of Homeland Security, which identifies 16 sectors as critical infrastructure. Their critical infrastructure sectors include farm and agriculture, healthcare and public health, communications, chemical, critical manufacturing, commercial facilities, dams, defense industrial base, emergency services, energy, financial, government facilities, information technology, nuclear reactors materials and waste, transportation and water. Many SAH orders are also accompanied by a requirement that non-essential business close or cease in person transactions. The latter would allow business to continue pick up or delivery options. Because SAH orders significantly limit where individuals can travel, they have received substantial attention in starting in March as a potentially important policy to deter individual movement and therefore decrease the spread of the virus.
As of April 3rd, 2020, only 5 states, North Dakota, South Dakota, Nebraska, Iowa, and Arkansas had no SAH orders and 4 states, Wyoming, Utah, Oklahoma, and South Carolina, had only local SAH orders.

Therefore, the second purpose of this briefing is to provide a timeline of the introduction of SAH orders across the United States. This briefing only includes SAH orders that apply to all citizens of a given state. While counties and cities in some states, including Tennessee, issued SAH orders for their residents before the state, they will not be included in this timeline. As of April 3rd, 2020, only 5 states, North Dakota, South Dakota, Nebraska, Iowa, and Arkansas had no SAH orders and 4 states, Wyoming, Utah, Oklahoma, and South Carolina, had only local SAH orders .
Before discussing the details of Tennessee’s policies, a timeline of early events in the spread of COVID19 is introduced to provide some context for the environment in which federal, state, and local governments were acting. Figure 1 includes this timeline and it starts on January 21st, 2020 the date in which COVID19 was first detected in the United States. In addition to early news events the timeline also includes the cumulative number of confirmed cases and tests. Confirmed cases capture the number of individuals who have tested positive for COVID19, not necessarily the total number of individuals with COVID19, which is currently unknown. The ability to test individuals is critical to identifying cases and giving policymakers better information to act on. Therefore, the total number of tests are included in the figure, and there are several early events that are useful for understanding the development of testing capabilities in the United States.
Figure 1: National Confirmed Cumulative Cases, tests, and early events.
Figure 1: National Confirmed Cumulative Cases, Tests, and Early Events

Emergency Use Authorization

First are the applications for Emergency Use Authorization (EUA), which are granted by the Food and Drug Administration (FDA) to allow for the use of unapproved medical products, including testing kits, to be used in an emergency. The Centers for Disease Control (CDC) announced it had developed a test on the same day the first case was identified in the United States, January 21st, 2020, which would allow for testing at the CDC in Atlanta, Georgia. They then applied for an EUA on February 3rd, 2020, which was granted the following day, to allow Public Health Labs to conduct testing. Kits were shipped to Public Health Labs on February 5th, and they were allowed to test patients who met CDC’s criteria for testing. Unfortunately, issues with these tests were reported by the CDC on February 12th, and they were unable to ship out newly manufactured tests until February 29th. On that same day, the FDA issued guidance that commercial labs could develop and use validated diagnostic tests prior to the completion of an EUA. This expansion in testing capabilities helps to explain the rise in testing in early March.
The timeline in Figure 1 also includes the White House guidelines, which were released on March 16th and were part of the 14 days to slow the spread campaign that was extended on March 30th to the 30 days to slow the spread campaign. The White House guidelines ask individuals to work or engage in school from home, maintain a normal work schedule for those employed in a critical infrastructure industry, avoid groups of 10 or more people, use take out or delivery options for restaurants, avoid discretionary travel, and do not visit nursing homes.

Tennessee Policy

This briefing considered all state level policies, developed primarily through executive orders, and the actions of the major cities: Nashville, which is in Davidson county, Memphis, which is in Shelby county, Chattanooga, which is in Hamilton county, and Knoxville, which is in Knox county. Due to the interest in the development of SAH orders, additional cities implementing SAH orders were also included in the timeline.
Table 1 contains the elements of the different policies, including a timeline number that can be used to link policies to their place on the timeline. Figure 2 includes the policy timeline and it shows how the implementation of the different policies coincided with the rise of confirmed cases and testing in the state. Because the first case in Tennessee wasn’t confirmed until March 5th, the timeline doesn’t start until March 3rd. The table contains several important elements of each policy: the date it was signed, the date it became effective, who in the state it applies to, the type of restriction, and the details of the restriction.
table 1: Tennessee state and local COVID19 policies
table 1: Tennessee state and local COVID19 policies
Table 1: TN state and local COVID-19 Policies
It is important to collect both the date an order was signed and the date it becomes effective because the dates possibly have different implications for individual behavior. The day an order is signed as a press release is generally issued to make the public aware that the government has issued new rules. However, the new rules will not become enforceable until the day the order becomes effective. These two dates are often, but not always the same and because the effective date captures the first day the policy must be followed it is used in Table 1 to order the policies and in Figure 2 to plot the policies.

The order in which different policies are developed in Tennessee follows a trend similar as other states. First the overall trend, whether it is at the county or the state level, is to move from mass gathering restrictions, to restricting businesses, and finally to issuing SAH orders. Also similar to other states, several local governments took the lead in issuing business restrictions and SAH orders, and the state followed shortly after. The SAH orders generally also included the closure of non-essential businesses that were described in the introduction.

The language used to describe the restrictions placed on individuals in the SAH orders is also important, as is evidenced by Governor Bill Lee’s issuance of a second order to amend the language in the first. The first statewide SAH order was signed on March 30th and it urged Tennesseans to stay home. However, after reviewing data that suggested individuals were not modifying their movement in response to the March 30th order, he issued a second executive order on April 2nd that required individuals to stay home. The language may, at least in part, convey the level of seriousness or the order to individuals.

Figure 2: Tennessee COVID Policy Timeline
Figure 2: Tennessee COVID Policy Timeline 
MG=Mass Gathering
BL = Business Limits
SAH = Stay at Home Order


Nationwide State Level Stay at Home Orders (SAH)

Figure 3: State wide Stay at Home order timeline
Figure 3*: State wide Stay at Home (SAH) order timeline
*Since the development of this briefing South Carolina implemented a state wide stay at home order. The order was signed on April 6th, and went into effect on April 7th.
Figure 3 contains the timeline for the introduction of statewide SAH at home orders that had been become effective by April 5th, 2020. The timeline uses the date the SAH orders became effective and shows that the first SAH order was released by California on March 19th, and a wave of SAH orders were issued on March 22nd and 23rd. Many of the states dealing with a substantial number of confirmed cases, such as California, New Jersey, Washington, and Louisiana have instituted SAH orders. While the state of New York has not officially introduced a SAH order, the governor announced the ‘PAUSE’ plan on March 20th, which asked individuals to cancel gatherings of any size, and practice good social distancing but used an executive order to close all non-essential business. The mayor of New York City then announced that effective March 22nd, at 8:00pm the city would enforce social distancing rules that included no non-essential businesses. This limited example highlights some of the challenges in tracking and interpreting how new orders and guidance may influence individual behavior. The figure also shows that Tennessee was included in a later wave of SAH orders that began in late March.
Table 2: SAH Order Language





As was previously discussed, the language used to describe the SAH order may influence behavior and so Table 2 contains the language used to describe how individuals were asked to stay at home. Of all states that issued SAH orders, only two, Connecticut and Kentucky, have done so through an announcement rather than an executive or public health order. Table 2 shows that most states either directed or ordered their citizens to stay home, which may influence how closely individuals follow the order.
It will be important for policy makers and future researchers to examine the contribution of both carefully to prepare for future outbreaks.
Understanding the role that local, state, and federal policies play in changing individual and business behavior will be important for understanding the spread of the virus and its impact on economic well-being broadly. While implementing new policies will explain some of the change in behavior, they will not explain everything. In particular, concerns with contracting or spreading the virus will likely lead individuals and business to modify their behavior before such policies are implemented. It will be important for policy makers and future researchers to examine the contribution of both carefully to prepare for future outbreaks.

This briefing provides a first step in the process of understanding how policy influences behavior by documenting and categorizing policies that restrict mass gatherings and business operations in the state of Tennessee. While this briefing cannot be used to determine the effectiveness of these policies, it can serve as a resource for future researchers seeking to answer these questions.


Where does the data in this briefing come from?


Case Counting and Testing
Confirmed case counts and total testing numbers came from two sources: The Center for Disease Control and the COVID Tracking Project. The COVID Tracking Project reports data collected and reported state public health authorities in a single website. For national cases and testing CDC data was used from January 8th until March 16th, 2020. COVID Tracking Project data was used from March 17th until the present. The choice to combine datasets was made for several reasons. First, the COVID Tracking Project did not begin to report data until March 4th. Second, the COVID Tracking Project did not include all states and territories until March 16th. Finally, because commercial laboratories began conducting tests and reporting them to the state, but not federal agencies, in March it was necessary to switch to the Tracking Project to gain a more accurate count of testing.

Confirmed cases and testing data for the state of Tennessee comes only from the COVID Tracking Project because the CDC does not report data at the state level.
Policies
To identify Tennessee state and local government policies the official website for each locality were identified and reviewed. Specifically, the website used to post news releases or executive orders was used to identify all relevant policies. If the locality had a site specific for their response to COVID19 it was also reviewed. A New York Times article monitoring SAH orders was also reviewed to identify additional localities with SAH orders outside of Memphis, Nashville, Knoxville, and Chattanooga. A hard copy of every order was obtained and reviewed to identify the key elements reported in this briefing.

National statewide SAH orders were identified using the Council of State Governments website. Then, a hard copy of every order was obtained and reviewed to identify the key elements reported in this briefing.
Send your additional policy questions to Dr. Jackie Yenerall or contact the CORE-19 research team. 
jyeneral@utk.edu core19@utk.edu | 865-321-1299

Coronavirus-19 Outbreak Response Experts (CORE-19) 

Dr. Jackie Yeneral

Dr. Jackie Yeneral, PhD

Yeneral is an Assistant Professor in the Department of Agricultural and Resource Economics. She is an expert in Public Health Economics. 



Dr. Kathleen Brown

Dr. Kathleen C. Brown, PhD, MPH

Brown is an Associate Professor of Practice in the Department of Public Health and the Program Director for the Master's in Public Health (MPH) degree. Her research focuses on the health and well-being of individuals and communities. She has experience in local public health in epidemiology, risk reduction and health promotion.
Dr. Katie Cahill

Dr. Katie A. Cahill, PhD

Cahill is the Associate Director of the Howard H. Baker Jr. Center for Public Policy. She also is the Director of the Center's Leadership & Governance program and holds a courtesy faculty position in the Department of Political Science. Her area of expertise is public health policy. She leads the Healthy Appalachia project. 
Dr. Kristina Kintziger

Dr. Kristina W. Kintziger, PhD, MPH

Kintziger is an Assistant Professor in the Department of Public Health and the co-Director of the Doctoral Program. She has worked in academia and public health practice, and comes to Tennessee from the Florida Department of Health, where she worked as an epidemiologist and biostatistician. She is an environmental and infectious disease epidemiologist.
Dr. Matthew Murray

Dr. Matthew N. Murray, PhD

Murray is the Director of the Howard H. Baker Jr. Center for Public Policy. He also is the Associate Director of the Boyd Center for Business and Economic Research and is a professor in the Department of Economics in the Haslam College of Business. He has led the team producing Tennessee's annual economic report to the governor since 1995. 
Dr. Agricola Odoi

Dr. Agricola Odoi, BVM, MSc, PhD

Odoi is a professor of epidemiology at the University of Tennessee College of Veterinary Medicine. He teaches quantitative and geographical epidemiology and his research interests are in population health and impact of place on health and access to health services. He was a public health epidemiologist before joining academia.
Dr. Marcy Souza

Dr. Marcy J. Souza, DVM, MPH

Souza is an associate professor and Director of Veterinary Public Health in the UT College of Veterinary Medicine.  Her teaching and research focuses on zoonotic diseases and food safety issues. 
Disclaimer: the information in this policy brief was produced by researchers, not medical or public health professionals, and is based on their best assessment of the existing knowledge and data available on the topic. It does not constitute medical advice and is subject to change as additional information becomes available. The information contained in this brief is for informational purposes only. No material in this brief is intended to be a substitute for professional medical advice, diagnosis or treatment, and the University of Tennessee makes no warranties, expressed or implied, regarding errors or omissions and assumes no legal liability or responsibility whatsoever for loss or damage resulting from the use of information provided.
Howard H. Baker Jr Center for Public Policy
1640 Cumberland Avenue
Knoxville, TN 37996
Phone: 865-974-0931
Email: bakercenter@utk.edu
Online: bakercenter.utk.edu
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