This column was last updated on March 14, 2020. Since then, the Centers for Disease Control and Prevention has made new recommendations on gatherings, and multiple states and cities have taken many of the steps outlined in this piece. In the absence of action from the federal government, states and cities must continue to take the lead.

The United States is at a tipping point: If transmission of COVID-19 is not slowed within the next week, the hospital system will be overwhelmed. The response of governments over the next week is critical. Since the federal government’s response has been woefully slow and inadequate, and public communication has been confusing and often inaccurate, it is up to state and local governments to lead in this time of crisis.

Testing is a critical feature of any public health response, and testing capacity for COVID-19 is now slowly ramping up. However, it is clear that testing capacity—let alone testing that is actually conducted—will not increase nearly fast enough to be able to provide the millions of tests that are needed. The strategy of testing, contact tracing, and containment is no longer an effective response.

As many experts have pointed out, the key goal right now is to “flatten the curve”—to slow transmission enough in the near term to spread out severe cases so that the hospital system is not overwhelmed. Measures that may seem like an overreaction at the moment are necessary to get ahead of the curve.

This column analyzes the epidemiology of flattening the curve, reviews state and local bans and closures as of today, and calls on governors and mayors to implement widespread bans and closures effective immediately. Based on the authors’ review, no state or city has implemented sufficiently aggressive measures.

Flattening the curve

According to a model developed by an epidemiologist at the University of Toronto, at the current track, more than 100 million Americans will become infected, including 9.4 million at the peak of outbreak. But if state and local governments begin aggressive measures today, the model finds that this number could be reduced to 513,000 infected at the peak.

According to current estimates, 5 percent of those infected will require intensive care beds. There are approximately 98,000 intensive care beds in the United States. On the current track, these estimates indicate that 470,000 people will require intensive care beds—far more than are available. In reality, this massive shortage will be even worse because these beds will also be needed for other conditions, including seasonal influenza. If state and local governments begin aggressive measures today, however, the number of intensive care beds required could be reduced to 26,650.

In many localities, substantial transmission is already occurring and incidence is much higher than the national rate. To keep the chance of at least one infected person being present at a gathering below 1 percent nationally, gatherings of more than 50 people must be banned. This threshold would help reduce the risk of transmission nationally through a total national caseload of about 66,000 people, although the risk varies substantially by geographic area. According to current estimates, each person infected spreads the virus to an average of 2 to 2 1/2 people.

For reference, at a recent conference of 175 Biogen executives, 77 people became infected. This case indicates that even bans on gatherings of more than 250 people are woefully insufficient.

1918 influenza pandemic An important historical example is a comparison of two cities’ approaches to the 1918 flu, which appears to have been as transmissible as the novel coronavirus but with a higher mortality rate. In St. Louis, where the mayor closed down major sites for public gatherings, the death rate rose but stayed relatively flat. Alternatively, Philadelphia implemented none of these social distancing measures, and the death rate skyrocketed during the fall of 1918. The different approaches of these two cities is a textbook example of the importance of flattening the curve. While COVID-19 is not the same disease and is occurring in a very different public health landscape, response to the 1918 flu suggests that reducing, if not outright banning, large social events is an effective method of flattening the curve.

Review of state and local bans

The Center for American Progress searched announcements by governors and mayors in press releases, letters, and social media postings within the past month.

The following states and cities have implemented bans on large gatherings:

Austin, Texas, banned gatherings of more than 2,500 people.

Illinois, Kansas City, Philadelphia, and St. Louis banned gatherings of more than 1,000 people.

New York state and Dallas banned gatherings of more than 500 people.

Colorado, Connecticut, Indiana, Louisiana, Maryland, Massachusetts, Michigan, Oregon, Vermont, Washington state with respect to three counties, the District of Columbia, and San Diego banned gatherings of more than 250 people.

New Mexico, Ohio, and Santa Clara County, California, banned gatherings of more than 100 people.

The following states and cities have issued recommendations, either to the public or to localities:

Richmond, Virginia, recommends canceling gatherings of more than 1,000 people.

Alabama recommends canceling gatherings of more than 500 people.

California, Florida, Idaho, Illinois, Maine, Minnesota, Nebraska, New Jersey, Pennsylvania, Rhode Island, Tennessee, Wisconsin, Wyoming, and Harris County, Texas, recommend canceling gatherings of more than 250 people.

Delaware, North Carolina, and Utah recommend canceling gatherings of more than 100 people.

Virginia recommends that localities and nonprofits limit “large” public events.

North Dakota recommends that localities with widespread transmission cancel events.

The following states have taken no action or provided little guidance: Alaska, Arizona, Arkansas, Georgia, Hawaii, Iowa, Kansas, Mississippi, Missouri, Montana, Nevada, New Hampshire, Oklahoma, South Carolina, South Dakota, Texas, Virginia, West Virginia, and Wyoming.

Among major cities located in states that have taken no action, Atlanta, Las Vegas, and Phoenix have taken no action.

The following states have closed schools: Florida, Illinois, Kentucky, Louisiana, Maryland, Michigan, New Mexico, Ohio, Oregon, Pennsylvania, Virginia, Washington, West Virginia, and Wisconsin. Major districts in the following cities have closed schools: Atlanta, Georgia; Austin, Texas; Boston, Massachusetts; Denver, Colorado; Indianapolis, Indiana; Los Angeles, California; Memphis, Tennessee; Nashville, Tennessee; Sacramento, California; San Diego, California; San Francisco, California; and Washington, D.C.

Call to action

In light of the urgency, and following a review of the epidemiological evidence and best practices among states and localities, the Center for American Progress is calling on governors and mayors to take the following actions immediately:

Ban all gatherings of more than 50 people.

For individuals who are at higher risk for severe illness, such as seniors or individuals with underlying medical conditions, ban all gatherings of more than 10 people. This includes gatherings at retirement and assisted living facilities.

Strongly encourage places of worship to cancel services and other events for groups of more than 25 people. Strongly encourage religious leaders to adopt additional social distancing modifications—staying more than six feet apart—for any small gatherings that continue.

Ban all concerts, conferences, and sporting events.

Close all schools and public colleges in jurisdictions with community spread—when the source of at least one new infection is unknown.

Close all gyms, bars, movie theaters, libraries, and community centers in jurisdictions with community spread.

Limit restaurants to half of their legal capacity in jurisdictions with community spread.

Strongly encourage employers to require employees to work remotely.

Lead by example: Cancel all public events of any size.

Require all state and local employees to work remotely to the extent possible.

Bans and closures should be put into effect for at least two to four weeks, with potential extensions, to allow health departments enough time to monitor and assess the extent of community spread. Congress must enact significant economic relief for small businesses and their employees who are subject to state and local closures.

The Centers for Disease Control and Prevention (CDC) has issued recommendations for school closure in jurisdictions where there is “substantial” community spread. However, without widespread testing, it is impossible to know where community spread is substantial, and the CDC’s guidance is vague. Where any community spread has been detected, states and localities must assume that the spread is or will become substantial.

Schools and community centers often provide access to free or reduced-price meals and snacks for low-income students and community members. As communities move forward with the closure of schools and community centers, it is imperative that officials consider ways to ensure that populations have their nutritional needs met. States and localities should consider strategies to deliver meals to populations in need or create centralized access points for people to pick up meals. In addition, policymakers must bolster food banks and food pantries in anticipation of higher demand and must boost nutrition assistance programs.

The U.S. Department of Agriculture has made waivers available in nutrition programs to provide flexibility. In Seattle, “grab and go” meals have been made available to all students at a number of schools throughout the city. Similarly, the District of Columbia is providing school meals at specific locations in each ward during the school closure period.

Conclusion

State and local officials understandably need more information from testing. However, the lack of adequate testing should not delay aggressive action immediately. Officials should assume that COVID-19 has spread to their communities. If it hasn’t already, it soon will in the absence of decisive action.

Zeke Emanuel is a senior fellow at the Center for American Progress. Topher Spiro is the vice president of Health Policy and a senior fellow for Economic Policy at the Center. Maura Calsyn is the managing director of Health Policy at the Center. Thomas Waldrop is a policy analyst for Health Policy at the Center. Nicole Rapfogel is a research assistant for Health Policy at the Center. Jerry Parshall is an associate director of State and Local Government Affairs at the Center.

To find the latest CAP resources on the coronavirus, visit our coronavirus resource page.