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Half of Calif. counties OK'd for reopening failed to meet at least 1 standard

The Stockton Record logo The Stockton Record 5/31/2020 By Nicole Hayden and Mark Olalde, Palm Springs Desert Sun
a person taking a selfie: Salon de Maria owner Maria Ortiz works with Elsie Vela on Thursday, May 28, 2020. Ortiz reopened her Visalia shop after Tulare County received approval from the California Department of Public Health (CDPH) to move fully into Stage Two of California's Resilience Roadmap. That includes allowing barbershops and hair salons to open following State modifications and guidance documents released this week. reopened her Visalia shop after Tulare County received approval from the California Department of Public Health (CDPH) to move fully into Stage Two of CaliforniaÕs Resilience Roadmap. That includes allowing barbershops and hair salons to open following State modifications and guidance documents released this week. (Ron Holman/Visalia Times Delta) © Provided by The Stockton Record Salon de Maria owner Maria Ortiz works with Elsie Vela on Thursday, May 28, 2020. Ortiz reopened her Visalia shop after Tulare County received approval from the California Department of Public Health (CDPH) to move fully into Stage Two of California's Resilience Roadmap. That includes allowing barbershops and hair salons to open following State modifications and guidance documents released this week. reopened her Visalia shop after Tulare County received approval from the California Department of Public Health (CDPH) to move fully into Stage Two of CaliforniaÕs Resilience Roadmap. That includes allowing barbershops and hair salons to open following State modifications and guidance documents released this week. (Ron Holman/Visalia Times Delta)

Two months after Gov. Gavin Newsom announced California would be the first state placed under a stay-at-home order lasting "many, many months," he began rolling back restrictions in favor of reopening businesses.

But when counties initially couldn't meet stringent reopening metrics — such as demonstrating a low number of new cases — Newsom loosened those criteria. Counties soon began receiving the green light to restore portions of their economies even though many regions still struggled to show a significant downward trend in COVID-19 cases and lacked resources to track and respond to potential upticks.

Of the 49 counties that received approval to speed along this quicker path to normalcy, 49% failed to meet at least one of the reopening criteria mandated by the state, according to an analysis by The Desert Sun newspaper in Palm Springs.

The Desert Sun reviewed every Stage 2 attestation form accepted by the state as of Friday. The counties' self-reported data points were analyzed against the Newsom administration's accelerated reopening benchmarks to determine which were adequate and which fell short.

Nearly a third of the counties that received authorization didn't have enough contact tracers, and more than 20% failed to conduct enough coronavirus tests on a daily basis.

As of Friday, counties that are home to 81% of the state's population had been allowed to move into the latter phase of Stage 2. Advanced Stage 2 reopening allows partial dine-in restaurant services, as well as a return schools with modifications for safety. To move into advanced Stage 2 reopening, counties were supposed to have met a variety of metrics:

  • A stable or decreasing number of hospitalized COVID-19 patients with a daily change under 5% or with no more than 20 total COVID-19 hospitalized patients on a single day in the past two weeks
  • Fewer than 25 new cases per 100,000 in the last two weeks or a testing positivity rate under 8% over the past week
  • At least 1.5 coronavirus tests conducted per 1,000 residents and testing availability within a 30- or 60-minute drive for 75% of county residents
  • At least 15 contact tracers per 100,000 county residents
  • The ability to handle a surge of at least 35% more hospitalized patients
  • The ability to care for vulnerable populations, including the homeless, but having space to house 15% of the homeless population

Of the nine counties yet to receive State 2 approval, seven are in the Bay Area, where local officials have made it clear they will move at their own pace. The other two are Contra Costa County and Imperial County, to the southeast of Riverside County and bordering Mexico. Imperial, which has about 180,000 residents, has been hit so hard by the pandemic that it has run out of hospital beds and is sending patients to Riverside and San Diego counties.

When Newsom published his initial list of benchmarks, very few counties were able to show the drop in cases and deaths the state demanded. Coalitions of counties from the Central Valley to Southern California lobbied Newsom to carve out exemptions.

Ten days later, the state handed down revised, easier-to-meet criteria. Salons, barbershops and places of worship were allowed to reopen sooner than planned. Those moves have been questioned by some health experts.

"If we develop reopening standards, we need to make sure we meet those standards before allowing counties to move forward," said Brandon Brown, a professor in UC Riverside's Department of Social Medicine, Population and Public Health. "This helps ensure we are all protected and that messaging is consistent and also respected. Otherwise, why make the standards at all?"

But even with diluted metrics, many counties missed the state's benchmarks.

When asked why states were being allowed to move forward when they couldn't even meet the watered-down standards, a spokesperson for the California Department of Public Health declined to comment on whether the agency offered certain counties flexibility in meeting specific standards.

While the state's spokesperson said the counties "met the specified criteria listed in the attestation," the agency did not take responsibility for ensuring counties hit all the reopening metrics.

"The state does not approve Local Health Officer Attestations," the state health department's spokesperson said. "The process involves a review to ensure that the Local Health Officer attests to meeting each of the specified criteria."

Essentially, if a county stated they met the standards, the state didn't challenge them.

Meeting state metrics doesn't fully mitigate threat

The quick reopening of economies around California — and across the country — is a signal that states are weakening their fight against the virus, said Jeffrey Shaman director of the Climate and Health Program at Columbia University.

"Unfortunately, we have a lot of giving up," he said.

A step-by-step reopening strategy aims to avoid a sudden spike in cases — which is exactly what happened in Lassen County.

Covering a sparsely populated area between Redding and Reno, Lassen County saw zero confirmed cases of COVID-19 until May 22, 11 days after it became one of the first counties approved to move more quickly through Stage 2 in mid-May.

After easily meeting the state's reopening standards, the county saw five new cases within two weeks. Although that still represented a low per-capita rate, it was a surprising about-face for a county that had evaded the virus for so long

Dr. Kenneth Korver, the county's public health officer, issued a new order on May 26, temporarily reinstating restrictions on dine-in restaurants, salons, places of worship and in-store retail. He said the county was "fully aware of the risk that the virus could come to our community" via residents of other areas visiting or Lassen residents traveling outside the county.

"Unfortunately, this did happen and we now have a serious problem. We need to contain the spread of the virus in Lassen County," Korver wrote in the public health order.

Lassen checked all the boxes on Newsom's criteria but still ran into trouble. Many other counties did not even meet the state's standards.

Alpine County, which borders Nevada near Lake Tahoe, was allowed to reopen despite county staff writing in their attestation form: "As far as we can tell, Alpine County has not met the requirement to test >1.5 per 1,000 residents per day."

The county's report justified the shortfall by noting that residents could get tested in neighboring counties, including crossing state lines to find coronavirus tests in Nevada. Similarly, Alpine's form noted that residents could seek hospital care in Nevada.

However, some counties that received approval without meeting testing capacity requirements had zero or only a few positive coronavirus cases in the past month, meaning the threat of a dangerous surge was low.

While Alpine County's case rate per 100,000 residents did not meet the state's standard, for example, the fact that its population is only about 1,100 skews the calculation. The county had just one positive case in the two weeks prior to submitting its attestation form. Experts acknowledge that rural areas are likely at lower risk than urban centers.

Populous counties still playing catch-up

Meanwhile in Southern California, more populous counties that failed to meet or barely met state standards were also approved for accelerated reopening.

In a surprise move, the state certified Los Angeles County's Stage 2 attestation Friday, only a day after the county submitted it. The most populous county in the U.S. — with some 10 million people — is the epicenter of California's coronavirus outbreak, and the number of new cases there climbs daily.

Statistics in its Stage 2 attestation form showed it was teetering on the edge of meeting many of Newsom's relaxed benchmarks. The county's ability to house its homeless population is likely to drop slightly below the 15% threshold when a temporary facility shuts down in June. Additionally, its rate of positive COVID-19 tests has risen several times in recent days, nearly breaching the governor's limit.

To the east, Riverside County, with a population just under 2.5 million, was approved despite having only three contact tracers per 100,000 residents while the state's metric was 15 per 100,000. County officials told The Desert Sun that it had nearly doubled that number by May 29 and has been training more people every week. Riverside County didn't meet Newsom's original standards but squeezed through following his changes.

San Bernardino County was also approved without an adequate arsenal of contact tracers, having just four per 100,000. In its attestation form, county staff wrote that the county would have 329 additional contact tracers trained by May 27. When asked on May 29, a county spokesperson said they met that number. Other countries across California have struggled to reserve even a few seats in the state's contact tracing training program.

Dr. Timothy Brewer, a professor of medicine and epidemiology at UCLA, said that densely populated Southern California remains behind on testing, contact tracing and other public health measures, and therefore needs to move with the most caution.

"This whole public health response, which should've been in place from the very beginning of the outbreak, still needs to be built out at the county and state level," he said.

Experts: Reopening will bring new cases

But public health experts concede that even the state's metrics, whether they were met or not, are educated guesses laid out on a messy chessboard.

"Nobody really knows for sure what the right way forward is," Brewer said, because the need for widespread stay-in-place orders to combat the virus pushed the country into "uncharted waters."

Knowing that the virus has an incubation period of about two weeks, experts discussed a waiting period between phases, for example, to mirror that timeframe and assess whether partial reopening caused a spike in cases.

Experts generally agreed that California's approach — considering a constellation of factors, reopening in stages and letting lesser-hit counties move more quickly — made sense. What will be key, they say, is for county health departments to continue bolstering their lines of defense while being willing to slow or pivot their reopening process according to new cases.

Even with best practices in place, there's no way to prevent an uptick as businesses and life start shifting back to normal, experts agree. Urban counties are at greater risk, Brown from UC Riverside said. What's debated is how big of a spike will manifest.

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A model run on Friday by doctors from Eisenhower Health in Rancho Mirage found that if all protective measures — stay-at-home orders and face coverings, for example — had been removed in April, the Coachella Valley could expect a peak of more than 60,000 COVID-19 cases in mid-June. With all measures in place, that peak would be fewer than 20,000 cases in early September. This means that slowly reopening could slot reality between those two peaks.

"There's no reopening without increased infections. Period," said Andrew Noymer, an associate professor of public health at UC Irvine. "You want to reopen, there's going to be more cases. I guarantee it."

Evidence from other states that have moved more quickly than California confirm this, Brown said. He worried that lax and confusing guidelines could lead to individuals forgetting the practices that helped flatten the curve in the first place.

"We are reopening and accelerating more quickly than I would like," Brown said. "We need to ensure that prevention methods — masks, physical distancing — continue as we loosen the restrictions."

The next line of defense that will help economies reopen, Noymer said, is widespread testing to determine asymptomatic carriers, and contact tracing to find and quarantine people with whom they interacted.

Many counties fell well short of goals for both metrics as recently as early this month.

Newsom forging ahead to Stage 3

California as a whole has done well to improve coronavirus testing, increasing its daily testing rate over the past week to about 130 per 100,000 residents per day, markedly closer to Newsom's goal of 150 daily tests per 100,000 Californians.

A Desert Sun analysis of state-level rates of testing around the country over the past several weeks suggests many parts of the U.S. are leveling off, with roughly half the U.S. reporting fewer daily tests last week as compared to the week prior.

A county-level analysis of recent daily testing rates around California counties also showed mixed results. Counties struggling to manage the virus have significantly increased their testing rates, with seven surpassing Newsom's aggressive goal. But, 28 counties — including San Bernardino — were at 50% of Newsom's benchmark or lower.

Currently, testing has been made widely available in many places for those who have symptoms or might've come in contact with a positive COVID-19 patient, such as at UC San Diego School of Medicine's hospital chain, said Dr. David Pride, the director of the school's Clinical Molecular Microbiology Laboratory.

However, "we still have these nationwide shortages of testing materials," Pride said, so testing capacity could be strained if universities and large companies want to get students and employees back to campuses, testing them all in the process. He said he would feel safest with California reopening areas that have an abundance of tests and so could shed more light on how much of the population is asymptomatic carriers.

Increasing contact tracing and testing directly benefits the workforce, Shaman from Columbia said, because it allows the economy to largely stay open by identifying specific people — not all of society — who needed to be quarantined. "A lot of states are simply reopening because the economic consequences are acute," he said.

But with varying health models, public health researchers say it's still unclear how the virus will respond to the summer, whether there will be a bigger surge in the fall and at what point herd immunity might be reached.

Regardless, Newsom is forging ahead with Stage 3, announcing on Friday that he would release new benchmarks within a week, while deferring even more to local leadership.

"The state is not dictating, not mandating those dates," Newsom said.

Nicole Hayden covers health. She can be reached at Nicole.Hayden@desertsun.com or (760) 778-4623. Mark Olalde covers the environment and can be reached at molalde@gannett.com. Follow them on Twitter at @Nicole_A_Hayden and @MarkOlalde.

a group of people sitting at a table in front of a window: Country Waffles in Redding reopened to diners on Wednesday, May 13, 2020, nearly two months after a March 19 California stay home order, due to the COVID-19 pandemic, forced restaurants in the state to close. (Hung T. Vu/Special to the Record Searchlight) © Provided by The Stockton Record Country Waffles in Redding reopened to diners on Wednesday, May 13, 2020, nearly two months after a March 19 California stay home order, due to the COVID-19 pandemic, forced restaurants in the state to close. (Hung T. Vu/Special to the Record Searchlight)
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