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Personal Protection Strategies and Shelter-in-Place for COVID-19

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

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

March 23, 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 provides guidelines on limiting the spread of the infection through personal protection strategies and understanding the purpose of Shelter-in-Place orders.  
This brief is part of a series that will be produced by the CORE-19 team over the next few weeks forecasting the health and economic impact of the virus. The Department of Health for the State of Tennessee is also providing ongoing updates. As this is an emerging issue dealing with a novel virus, information included here is potentially subject to revision as new research and data emerge. 

COVID-19 Case Updates

As of Sunday, March 22, 2020, according to tracking of COVID-19 by Johns Hopkins University, the virus has spread to:
Global: over 335,957 cases with 14,632 deaths and 97,882 people recovered. 
  • In 10 days, the global infection rate has increased by 2.4 times (244%) and deaths have nearly tripled. 
United States: 33,276 cases with 417 deaths and 178 people recovered. 
  • In 10 days, the US infection rate has increased by 26 times (2,624%) and there are now 12 times the number of deaths. 
Tennessee: 505 cases in 41 counties, 2 deaths, with 0 recoveries
In 10 days, Tennessee's infection rate has increased 28 times (2,805%) and the disease has expanded into 36 new counties. 
See this link for the numbers the Center published from 10 days ago on Friday, March 13, 2020:

Testing for COVID-19: Some of the increase in the US and Tennessee confirmed cases may be due to increased detection through testing and public awareness. The US, however, is still far behind other countries in the number of tests conducted. 

As of Sunday evening, March 22, the CDC reports that the US, through public and private labs, has conducted a total of 71,870 tests for COVID-19 since January 18, 2020. TN State Public Health Laboratory has conducted 909 tests.

Personal Protection Strategies: What YOU Can Do

Many are already aware of the guidance by the CDC to prevent spreading or contracting COVID-19 through handwashing and social distancing (6ft) among other strategies.
At the same time, individuals are dismayed to find empty shelves where hand sanitizer, rubbing alcohol, bleach, masks, and gloves are normally stored. In addition to the CDC recommendations, here are some things that you can do with the existing resources to protect yourself and others: 

Shelter-in-Place: What WE Can Do

Most communities are aware of the guidance and importance of social distancing to slow the spread of COVID-19, however there is still more that can be done at the community-level to protect everyone. Due to the exponential growth curve that is possible with a novel disease for which there is currently no vaccine, treatment, or cure, it is essential to act quickly. 
What does a "Shelter-in-Place" order achieve? 
A "shelter-in-place" order limits the movement of individuals to essential tasks and services for a set duration of time, thereby decreasing the likelihood that those who are infected will come into contact with others and spread the disease.
It is important to note that the incubation period for COVID-19 is estimated to be 2 to 14 days, with an average of 5 days before symptoms emerge. While individuals are thought to be most infectious when they are symptomatic, there is a possibility that individuals may be contagious before the onset of symptoms (around 24-48 hours prior to symptoms).  
This means that some individuals who are unaware that they are carrying the virus may be interacting with others at grocery stores, gyms, or other gathering places. The purpose of a "shelter-in-place" order is to limit such interactions, as existing directives to not go out when feeling ill may be insufficient to slow the spread of the disease.
Importantly, the goal of these orders is to reduce the number of cases and allow the healthcare system time to meet increasing demands for testing, treatment, and other services. These orders also protect workers in essential industries from being exposed to the virus.
Why now? 
On average, and as noted in a recent petition released by the Tennessee Medical Association, cases of COVID-19 are increasing at a rate of 55% per day in Tennessee.
In other words, confirmed cases in Tennessee are doubling in number in less than 2 days. If the current rate of growth in cases continues, more than 5 million people in the state will have been infected by April 12, Easter Sunday. Based on the crude case-fatality rate of 1%, this means that 50,000 Tennesseans will die of COVID-19 by early-to-mid May 2020. 
In comparison, 31,157 people died in the entire country of the seasonal flu in 2018-2019. 
Here are scenarios, illustrated in Figure (1) below, for Tennesseans if cases double: 
  • every 2 days (yellow): 5 million infected by April 12th
  • every 3 days (blue): 6 million infected by April 23rd
  • every 4 days (green): 5.9 million infected by May 3rd
  • every 5 days (dark blue): 5.5 million infected by May 12th
  • every 7 days (red): 5.5 million infected by June 1st
  • every 10 days (grey): 1.38 million infected by June 13th-- 100 days after the 1st case was confirmed in the state.
Figure 1: Projected Tennessee COVID-19 Cases Based on Doubling-Time
TN COVID-19 Projections
Figure (1) and the numbers it shows demonstrate the unrelenting nature of an exponential growth curve. In a recent January 2020 study published in The Lancet and using data from the outbreak in Wuhan, researchers estimated the doubling time of COVID-19 to be 6.4 days. While this is a longer timespan than the data for Tennessee suggest, to think about this another way:
If you think about exponential growth as having borrowed $1 from a loan shark, at a daily compound interest of 25% (e.g., a doubling-rate of 4 days) and assuming that you don't pay back the loan, by day 18, which is where we are now in Tennessee, you would owe $44. Not too bad. But by day 100, you would owe $3.9 billion.
Even if the loan shark charged you 16% daily compound interest (e.g, a doubling rate of 6 days), by day 100 you would still owe $4 million. 
~ Example adapted from a March 17, 2020 
New York Times article by economist Thomas Friedman
A team of data scientists, epidemiologists, and public health experts also recently released a state-by-state model of hospitalizations due to COVID-19, as well as hospital capacity. Based on this model, if no action is taken now, by April 8th, hospitalizations for COVID-19 will exceed capacity of Tennessee hospitals (See Figure 2 below). 
Figure (2) Hospitalization Burden Based on Different Policy Choices
Hospitalizations for COVID-19 Under Different Scenarious
These examples demonstrate that small numbers of initial cases can give a false sense of security that the problem is not as significant and that there is still more time to take action. Based on existing evidence, this is incorrect.
Some experts now think that containment is no longer possible and the only strategy is to "flatten the curve" or to mitigate the worst effects by spreading out cases over an expanded time horizon.  

Additional Information 

Homemade Protective Masks
In an article published in 2013 in the journal Disaster Medicine and Public Health Preparedness, researchers at Cambridge University tested the effectiveness of homemade facemasks using particles that are 5 times smaller than the virus that causes COVID-19.
The researchers concluded that a homemade mask from a single layer of a cotton t-shirt could filter out approximately 50% of 0.2 micron particles, which is smaller in size than the coronavirus. 
It is important to note that a homemade mask does not meet the clinical standard of personal protective equipment (PPEs) for those working in medical settings and should only be used as a last resort in those settings according to the CDC. However, a homemade mask is one way for members of the public to increase their own protection against the spreading or contracting the virus in everyday settings, such as at the grocery store.
Members of the public should consider donating any boxes of n95 or surgical masks they have to the nearest hospital. 
Figure 3: Non-Sew Homemade Facemask (CDC)
CDC Mask Instructions
 Household Cleaning Products 
The Environmental Protection Agency (EPA) has provided an expanded list of household cleaners approved for COVID-19 disinfecting. This list can be a bit difficult to understand, but the American Chemistry Society has provided a more user-friendly list based on the EPA's registration number system for chemical components in approved cleaners. 
The CDC also has more gudiance on disinfecting your home here
For more information on the health impacts of COVID-19 read our previous policy brief on the topic:
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. 

Coronavirus-19 Outbreak Response Experts (CORE-19) 

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 Veternary 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. 
Howard H. Baker Jr Center for Public Policy
1640 Cumberland Avenue
Knoxville, TN 37996
Phone: 865-974-0931
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