The past month of America’s coronavirus crisis has looked different.
Stores, restaurants and workplaces reopened. People became more comfortable leaving their homes. Mass protests over the death of George Floyd at the hands of Minneapolis police dominated television and social media just as fewer people talked about wearing masks and social distancing.
All the while, the virus waited, patiently.
“People have the perception that something has fundamentally changed, but nothing has fundamentally changed,” said Dr. Ali Khan, who became dean of the College of Public Health at the University of Nebraska Medical Center after leading preparedness efforts at the Centers for Disease Control.
“90 to 95% of Americans are still susceptible. The virus is still out there… The basic biology of the virus has not changed nor has the basic strategy for fighting it,” Khan said. “Until we get this disease under control, we should expect to see continued spikes of illness.”
And that’s what is happening.
The United States has seen new cases climb from about 21,000 a day the last week of May to nearly 23,000 a day this week. Positive tests and, in some places, hospitalizations have spiked, too, leading many to wonder if a change in behavior caused outbreaks in states such as California, Arizona and Florida.
But neither protests or more people leaving home explain the surge of new COVID-19 cases, a USA TODAY analysis of counties with at least 100 cases has found. Residents of counties with growth of 25% or more over the previous two weeks left their homes at the same rate as people in counties without a surge of new infections, according to cell phone location data compiled by the company SafeGraph.
And large protests were as common in counties without outbreaks as in others – although those events could have seeded the virus broadly, and could still lead to outbreaks.
For now, surges seem to be most intense in counties that had avoided the worst coronavirus outbreaks earlier this year. Areas with recent spikes remain lower overall, averaging 614 confirmed coronavirus cases per 100,000 people. Those with slower growth have an overall rate of 860 per 100,000.
No single cause seems to explain why some places have seen spikes and others haven’t.
“I don’t think it’s clearcut. I think it’s multifaceted,” said Ted Ross, director of the Center for Vaccines and Immunology at the University of Georgia.
Reopening and protests
Experts speculate that people living in places that were not hard hit by COVID-19 earlier this year may be less diligent about wearing masks and maintaining safe social distance, making them more likely to spread the virus once it arrives in force.
“They’re becoming frustrated and tired. And the ability to remain vigilant for a long period of time is difficult, particularly when they don’t see the risk right in front of them,” said Mercedes Carnethon, the vice chair of preventive medicine at Northwestern University Feinberg School of Medicine. “How long can you be afraid of the boogeyman if the boogeyman is never actually knocking on your door?”
Others say that the months of closed economies and lockdown orders decreased the prevalence of the virus enough that large gatherings may carry a lower risk of becoming a mass-spreading event than in early spring.
That grace period won’t last forever. If large crowds continue to gather at church, the beach and bars without wearing masks and without social distancing, experts said it’s only a matter of time before an infected person triggers a new outbreak.
“Once you get some disease into a tinderbox situation, it can explode fairly rapidly,” said Dr. Lisa Maragakis, the senior director of infection prevention at Johns Hopkins Health System.
Because public data is compiled at the county level, it is impossible to analyze important granular details about particular social groups and individual risk factors.
For instance, a spike caused by people who became ill at protests might be obscured by the fact that the prevalence of coronavirus in their home community declined because of preventive measures. Or, a spike might be tied to a single mass-spreading event, like a church service, rather than the general public leaving their homes more often.
Additionally, it can take weeks for mass spreading events to cascade enough that they cause a noticeable surge in confirmed cases, especially if a state is not adequately isolating the first people who show symptoms and tracing their contacts with others.
Carnethon said county-level figures are a form of “ecological study.” That kind of analysis is helpful for understanding the big picture of how prevalent the coronavirus is in the community, but cannot pinpoint particular causes of spread.
“Ecological studies are great at giving hints where there could be patterns of association,” she said. “It doesn’t give us the data to determine whether an individual’s behavior is associated with an individual’s outcomes.”
Sometimes good individual choices are not enough to protect communities, experts said.
Minority groups are disproportionately represented among essential workers who have faced ongoing exposure to coronavirus, including at meatpacking plants and nursing homes, where they dominate the workforce.
USA Today has previously reported that meatpacking plants have become epicenters of outbreaks in many communities because of crowded work spaces, poor hygiene controls and policies that discouraged sick workers from staying home. Similarly, many nursing homes have been cited for poor infection controls that put both residents and staff at risk, USA Today has reported.
That appears to be a factor in Arkansas’ latest large outbreak.
In Washington County, Arkansas, concern about the increase in Hispanic and Asian households far outweighs any impact from protests, said Jennifer Dillaha, epidemiologist and medical director for immunization and outbreak response at the Arkansas Department of Health.
The Fayetteville area has seen among the biggest increases in coronavirus cases in the country, adding 792 of its 1,970 cases within the past week. While Fayetteville had large protests, she said people reporting new cases aren’t connected to them.
Instead, Dillaha said most cases have been tied to workers at poultry processing plants, which includes Latinos and Asian Americans. Some of the newest cases also have been among children. She said she did not yet have enough information to know if the kids contracted the virus from family members at the plant or from somewhere else in the community.
“We know that the Latino population is a young population, and they tend to have large households,” Dillaha said. “So our concern is that it’s spreading in the homes and social groups outside the homes.”
In the face of the dramatic increase in cases, Fayetteville this week started to require people wear cloth face coverings in public. Dillaha said it was the first such order in the state, but she wouldn’t be surprised to see more.
“If we don’t get a handle on cases in the worksite, then we will have difficulty when the University opens up. It all works together, if any one area is not addressed, the other areas will be affected.”
In Larimer County, Colorado, cell phone location data shows the rate of people staying home declined by 12% from May to June. In late May, large protests broke out, with hundreds gathering to call for changes to policing.
Yet new cases there are growing at their slowest rate – fewer than five cases a day over the past week – since the first patient was identified back in early March.
Katie O’Donnell, a public information officer for the Laramie County Department of Health and environment, attributes the decline in cases to a real change in behavior. The county issued a face mask order on May 2, asking businesses to require the coverings as a condition of reopening.
“We got to reopen our businesses because we were willing to have these face-covering orders,” O’Donnell said. “People hate it. People complain. But for the most part people understand if you just wear these face coverings, we can begin to reopen.”
The decline in new cases largely overlaps with that order. The week before it went into effect, the county identified 75 new cases. The next week there were 46. Last week, there were just 27.
That’s not due to a lack of testing, O’Donnell said, as testing has become more widespread. And protesters, in particular, have been taking advantage.
“I get a surprising number of calls from them, after they protest,” she said, adding that interestingly “our protestors are wearing masks, and trying to keep their social distance.”
By comparison, Arizona has not mandated masks statewide and until recently local governments were barred from issuing their own orders, one reason experts suspect new cases are cropping up faster there than in most of the country.
“As things opened up, a lot of folks may not have fully understood all the practices we should continue,” said Dr. Joshua LaBaer, director of the Biodesign Institute at Arizona State University. “When I go out on the weekend, I see lots of people walking around without masks. Not long ago, I passed a soccer game with clusters of parents chatting without masks as if there’s no pandemic going on.”
Researchers at the institute estimate the rate of transmission grew 40% in the first two weeks after the state started to reopen May 11. On that day, the state reported 261 new positive tests. On Thursday, Arizona reported a record high of nearly 10 times that many: 2,519 new cases.
Counties with the fastest spread of coronavirus in June are not the same ones that saw surges in March.
For instance, Apache and Navajo Counties, which include large chunks of the rural Navajo Nation, have some of the country’s highest rates of overall infection, with more than 2,500 people infected for every 100,000 residents. But the rate of spread there has slowed dramatically in recent weeks as tribal officials have ordered lockdowns even as residents of non-tribal lands moved forward with Arizona’s reopening plan.
Each person with COVID-19 in Apache County is now infecting 1.02 other people, down from 1.7 in early April. In Navajo County, the rate has dropped from 1.5 to 1.1. If the figure drops below 1, it means that the outbreak is contained and will peter out.
In a recent call, President Donald Trump urged governors to describe the nationwide growth in positive tests as the result of increased testing, saying there should be no cause for alarm.
Last last week, Arizona Gov. Doug Ducey, a Republican, described a spike in cases as the result of increased testing. A few days later, his tone changed. On Wednesday, he urged Arizonans to wear masks and authorized cities and counties to establish local mandates, acknowledging that coronavirus cases were growing.
LaBaer echoed other experts who said easier access to testing does not fully explain the increases.
“You can tell by the number of hospitalizations, by the number of ER visits,” he said. “There are more COVID-19 cases and more transmission out there.”
The five-day average of tests in Arizona shows 17% have been positive, well above the 10% threshold considered a sign of adequate testing by the World Health Organization. It also is higher than a peak in late April at 14% and the low of 7% seen when the state announced it would reopen.
Pointing to a graph showing the number of new cases announced each day, LaBaer dragged his pointer up and to the right.
“That’s the foot on the accelerator,” he said. “That means day over day there are more cases and the virus is actively spreading in the community.”
Contributing: Mike Stucka and Dan Keemahill