Dr. Schaffner

VUMC professor of preventive medicine and infectious diseases Dr. William Schaffner

Gov. Bill Lee announced on Monday a phased reopening of nonessential businesses starting next week with continued social distancing restrictions, including staying six feet apart and discouraging gatherings of 10 people or more. 

The order excludes counties with large populations — including Davidson, Shelby, Hamilton, Knox, Madison and Sullivan counties — that have larger outbreaks and their own county health departments to track the spread and make decisions on reopening. The mayors of the state’s four largest cities have already teamed up in a coordinated effort to reopening these higher-risk zones. On Tuesday, Nashville Mayor John Cooper said he will extend the Safer at Home order to May 1, for now, but a 25 percent spike in active cases over the weekend has the county reassessing whether that will have to be extended.

The state began expanded testing last weekend at 33 sites across Tennessee, administering tests for free to anyone who wants one regardless of symptoms. Over the weekend, the National Guard and Department of Health were able to test more than 11,000 people — increasing the overall testing volume 10 percent. Department of Health Commissioner Lisa Piercey also announced the transition of 230 state employees to its contact tracing initiative, an important component to tracking COVID-19's spread, more than doubling its capacity. 

Widespread testing is key to being able to reopen the economy without causing another surge in COVID-19 cases and undo the progress the past month of social distancing has done to slow the spread of the virus. But Lee didn’t wait for the results from the first round of expanded testing, which began to be reported publicly Tuesday afternoon, to make his decision about reopening. Although he said his administration doesn’t fully understand the scope of the spread, they are using metrics like transmission rate to make their decisions.

The state began testing in rural areas a little over three weeks ago with the launch of the National Guard’s 35 mobile assessment centers. It came as White House infectious disease expert Anthony Fauci said states need to begin shifting their efforts to figuring out what was going on in parts of the country where an outbreak wasn’t obvious to begin understanding the infection’s spread.

At that point, the state wasn’t releasing testing volume data per county; it began to after the launch of mobile testing sites. Most non-metropolitan counties have administered several hundred tests on average as of Tuesday afternoon, ranging from 24 tests in Hancock County, where there are no confirmed COVID-19 cases, to nearly 1,000 tests in nearby counties, such as Anderson and Maury counties. 

State governors are experiencing pressure from President Donald Trump and his administration to begin reducing regulations in some parts of the country as the economy continues to take a hit and demonstrations pop up, including in Tennessee, to protest shut-in orders. On Tuesday, U.S. Attorney General William Barr said the Department of Justice would consider taking legal action against states whose social distancing policies are too strict and impose on an individual's civil liberties.

Lee has been working with a coalition of Southeastern Republican governors, including Florida, Georgia, Mississippi, Alabama and South Carolina to strategize the reopening of the region. Georgia has already begun reopening nonessential businesses, including hair salons, tattoo parlors and gyms, and intends to open restaurants next week. Alabama, however, extended its shut-in order until May — a departure from the rest of the group. Lee says he will have a more detailed plan for the state’s reopening later this week.

In this Q&A with Vanderbilt University Medical Center professor of preventive medicine and infectious diseases Dr. William Schaffner, the Post explores the data, or lack thereof, behind the decision to reopen Tennessee.

Do you think we have enough data about COVID-19’s spread to begin reopening?

I think by the time the lock-down order is released, we will have enough data. And so far the data look very optimistic. So I think that as things gradually being able to open up, we in public health and infectious diseases are going to be urging everyone to be cautious about that to continue the social distancing because that is a key part to everything. 

Let’s keep wearing our masks in public, keep the hand hygiene going, and keeping the spacing out there. And as we do open up, let’s be cautious about our travels about. Let’s keep them to the essentials.

Early on it was indicated we would need widespread testing, even antibody testing, before even considering reopening. How do you justify not having that in Tennessee?

I’m not so sure everyone called for antibody testing. It is a useful adjunct had it been available, but we’ve expanded our capacity to do testing for the virus: the classical nasal swab sort of testing. That is being opened up much more widely in the state now. And local and county health departments are more intent, not only on case identification but contact tracing. And indeed, in Nashville, we have more people hired to do just that. And so, I think we are in much better shape than we were even two weeks ago to be able to engage in the first phase of opening things up.

Do you think contact tracing is able to keep pace with tracking COVID-19’s spread now?

I wouldn’t suggest we are in containment phase now. I think we are in a combination of containment and mitigation. I think we are in better shape as regards to capacity to do contact tracing. I’m not sure we can do that for every case that has been identified; that would still be a lot. And as we do more testing, we will find more cases. There are more cases out there than what we are identifying, but the key metric is persons admitted to the hospital with confirmed COVID infections. And I’m knocking wood now [that] they have been flat or even kind of coming down in many parts of the state. As we open things up, the major metropolitan areas are each different and they may go a little slower because there have been more cases in those areas.

We just started testing in rural areas about three weeks ago. What sort of trends did you see coming out of those areas that make you comfortable with making the call to reopen?

"Comfortable" is an interesting word. I’m thinking of another C-word. I’m "cautiously" comfortable. Obviously, the virus is literally everywhere in the state. But as we anticipated, because people live more closely together in metropolitan areas, there is substantially more infection in the metro areas than in the rural areas.

Right, but do you think you know the general scope of the outbreak in these more rural areas? 

We have a general idea but with more testing, particularly testing over time, we will get, first of all, a more definitive picture as well as being able to trace things over time. How are we doing going forward because the national plan always tells us that we should enter a phase and then evaluate how we are doing. In other words, mark time for a bit, get the data, look very carefully at what we are doing, before we push on to the next phase. That sounds very prudent to me.

Instead of being proactive with data, it sounds like we are having to take a reactive, possibly experimental, approach to this. Do you disagree?

This is a new virus. Everybody says this is something that we have not encountered anything quite like it before. Everything we do is an experiment, and so at each stage as you can consider these all really little experiments one after another, that we shouldn’t be too eager to move from one mini-experiment to another. We ought to do this in a graduated, gradual fashion. Each time looking at the information — and I hope we keep getting more and more information from our testing — to make us cautiously comfortable to make us move into the next phase.

What trends will you be looking for as we go in and out of these phases?

There are a whole series of things, but the metric I would be looking at first is how many people have been admitted to the hospital with confirmed COVID. Another is the proportion of people who are tested who turn out to be positive. And then, as we get more information in not only the metropolitan areas but rural areas as well, we will get a better sense of how this virus had penetrated to all the corners of the state.

There’s been a lot of talk about the balance between the economy and health — how do you have that conversation with yourself? 

I think of it as a tightrope walker, who is out there on the tightrope, holding that pole to help themselves balance. If you lower one side or raise one side too much, you get into the danger zone. So keeping the two ends balanced is very difficult. Don’t try to run too quickly across that tightrope. Just do it very very cautiously and try to keep things in balance. Because there are advantages and disadvantages to staying too much on one side or the others.

How should people interpret the World Health Organization’s guidelines for lifting social distancing restrictions as it relates to Tennessee? We haven’t satisfied its criteria for reopening yet.

A guideline is exactly that. It’s a guideline which is going to be adapted and interpreted in slightly different ways across this entire country. So, we shouldn’t be entirely surprised that our relatives living in the state of Washington are doing things a little bit differently than what we are with whatever we are doing at the moment.  They will be interpreted somewhat differently.

Is there anything else you think is important to add?

We are a large, diverse country, and some states are going to move more rapidly than others. Some municipalities are going to move more rapidly than others. I don’t think that New York City or New Orleans and Detroit, for example, are going to rush to open up. They may be among the most cautious because they were hotspots. Even within our own state and others, parts of those states may move a bit more rapidly than others. Some of that will cause confusion. And so, there is the importance of sustained clear communication both at a higher level and at the level where we spend the most of the time in our own communities.

This post originally appeared in our sister publication, the Nashville Post

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