Meharry Medical College President and infectious disease expert Dr. James Hildreth speaks at a virtual COVID-19 press briefing in Nashville. 


Tennessee's push to reopen in May led to COVID-19 outbreaks that increased active cases nearly ninefold in three months while filling hospital beds across the state. Now, the state faces its latest test: reintroducing in-class learning to the majority of schools.

Tennessee was among the first states to reopen from a month-long closure of nonessential businesses in late April despite a relative lack of testing data and no obvious decline in the virus’ spread. Along with several other states in the Southeast run by governors who worked together to create reopening strategies, Tennessee has experienced rapid increases in cases of COVID-19 and subsequently in hospitalizations and deaths. Those numbers appear to be plateauing but are still markedly higher than four or eight weeks ago.

In Tennessee, White House Coronavirus Response Coordinator Deborah Birx said the outbreak has reached an inflection point where immediate action is needed or the trajectory of the epidemic will go into “full logarithmic spread.” During her visit to Nashville last week, Birx directed Gov. Bill Lee to issue a statewide mask mandate and close bars, where the transmission of COVID-19 occurs the most, according to contact tracing investigations. Lee has refused to take on such strategies, though, and has committed to not shutting down businesses in the future. Instead, he has launched a marketing campaign and is relying on individuals to buy in to safety guidelines.

“The virus reservoir — that is the number of people who are infected — is much higher than it was just a couple of months ago,” Meharry Medical College President and infectious disease expert James Hildreth told the Post. “If you look at the map in Tennessee, the biggest difference between March and April and now is that the rural areas of the state have now been touched by the virus and so since [Nashville is] a regional health center for much of Tennessee, the things that happen in those places could dramatically impact our ability to take care of people in the hospitals.”

Hildreth said reopening schools amid this level of penetration from COVID-19 will only increase the risk of outbreaks in the surrounding communities — which could have confounding effects across the state. Although school districts in Nashville and other metro areas have opted for virtual learning until more progress is made on containing the virus, rural school districts have heeded advice passed down by Lee, who has said in-person learning is the “medically sound, preferred option."

But those same rural communities are the ones starting to bear the brunt of the pandemic. As of a few days ago, all 95 counties are reporting what the state has deemed to be “unacceptable” rates of transmission. 

As the majority of schools across the state begin reopening this week, Hildreth is fearful outbreaks will only worsen as children begin making more contacts and spread the virus around. Although children have a less likely chance of experiencing hospitalization or death from COVID-19, they can serve as hosts and can transmit the virus to vulnerable individuals. 

“We all know a few cases can turn into a large number of cases if something is not done to stop transmission,” Hildreth said, underlining the need — now perhaps more than ever — for all municipalities to adopt mask mandates and impose regulations on high-risk transmission hubs like bars and restaurants. “The point is that the mandates are needed to keep what might be a small number of cases in those areas from exploding into larger number of cases. That’s the point. Just because things look like not much of a challenge now, if you don’t take steps to keep it that way, they find the number of cases will explode.”

Such an explosion would come with the risk of overwhelming local hospitals less equipped to take on high volumes of new cases as they transition into flu season, when bed availability is traditionally running near capacity limitations. If rural hospitals — several of which serve multiple counties — run out of beds, patients could be sent to facilities in Nashville and other metro areas where the outbreak is beginning to stabilize. Hildreth said outbreaks will likely continue to pop up sporadically between counties until there is a coordinated statewide response.

“I’m more concerned that we don’t have a statewide approach to this because at the end of the day what happens in the other places in Tennessee will impact Nashville,” he said. “We aren’t fighting the virus in isolation.”

The key to success will be reducing the number of active cases throughout the state in the next few months, Hildreth said, in time for flu season when hospitals often operate near capacity limits even without the additional strain of a pandemic. States that are struggling with outbreaks now will likely have to revert to stronger mitigation efforts — even issuing new shut-in orders — to protect hospitals from becoming overwhelmed. Much of that will be influenced by what kind of flu season hits in the fall, he said. 

Tennessee Department of Health officials said recently they are not collecting data on outbreaks that occur in individual schools, instead leaving it up to school districts to communicate cases of COVID-19 to their respective communities. The state is, however, reporting infections among school-aged children within the state, which has increased nearly 44 percent — from 7,200 cases to 10,400 — in the past two weeks.

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

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