Has SC ‘flattened’ the coronavirus curve? Experts say cases could surge as state reopens

As businesses, restaurants and public gathering places across the state reopen, South Carolina leaders and health officials have stressed the importance of continuing to practice social distancing to prevent the spread of the novel coronavirus.

But some South Carolinians have not heeded their words, gathering in large groups as the number of coronavirus patients in the state continues to increase daily. On May 4, the first day restaurants were allowed to open outside dining, people were caught gathering en masse in Columbia’s Five Points district. Residents flocked to parks and beaches as they were allowed to reopen.

Pinpointing exactly the observations or data driving officials to reopen the state has been tricky.

S.C. Department of Health and Environmental Control officials, until Friday, have offered no specific statistics to show conditions are safe for reopening. McMaster has repeatedly said it’s not one data point, but his observation of South Carolinians’ “common sense” and adherence to social distancing recommendations. Yet even as McMaster was reopening retailers, the state had not met White House recommendations for kicking off the economy.

While state health officials say the curve of infection is flattening, they’ve been vague about how they’re making that assessment, and the state has not seen a significant drop off in COVID-19 cases, experts say.

And now, as McMaster continues to roll back restrictions on businesses — saying he wants to reopen the economy as quickly, but as safely, as possible — health experts say critical safeguards still need to be put into place. The state owes the stabilization in cases it has seen recently to stringent social distancing policies, those experts say, predicting another wave of cases could be waiting right around the corner if residents drop their guard.

“They’re sort of treating the epidemic like this wave that we’re getting is it. And it’s not,” Medical University of South Carolina Global Health professor Michael Sweat said. “This is all under very high levels of social distancing right now and because of that, we had a remarkable reduction in the transmission. But as soon as that gets loosened up, we’re going to have to watch real closely what happens because it could very rapidly kick off again.”

As McMaster announced he would lift restrictions on close-contact businesses Monday, reporters asked state epidemiologist Linda Bell whether she thought reopening the state was safe.

While she did not provide a clear answer, Bell said DHEC’s guidance was “really not about recommending what (businesses) should or should not do.”

“What we can do for the people who are looking to resume their normal activities is to provide them the guidance that is available to do it as safely as possible,” Bell said.

“We want everyone to be aware that we continue to see significant disease transmission in the community. We want everyone to be aware that they’re still potentially at risk,” she added.

What does the data say?

Both DHEC officials and McMaster have largely remained unclear on what data they are relying on as the state reopens.

In some ways, officials are trying to capture a glimpse of a moving target.

DHEC’s Bell has said the department is using models created by the University of Washington’s Institute of Health Metrics and Evaluation to evaluate whether the curve is flattening, data which is also used by the White House. But that model is constantly being modified, and the date of peak cases is constantly shifting, Sweat said.

“They’re kind of constantly updating, but I don’t think they’re far from the mark,” Sweat said.

On Friday, for the first time, DHEC pointed The State to the specific metric the agency is using to evaluate the curve of infections in the state: a graph depicting the number of cases released per day.

The chart shows a fluctuation in cases from day to day, with no clear-cut, consistent drop in cases. For example, from April 17 - 20, cases appeared to be declining to 64, but on April 21, DHEC officials identified 172 cases, a clear jump. That trend is reflected several times throughout the chart.

The most cases announced on a single day was 276 on April 16. In May, the most cases identified on any one day was 238, which was announced on May 8.

Over the last 14 days, the number of cases announced each day by DHEC has fluctuated wildly, ranging from 93 to 238. Four of the last 14 days have brought more than 200 cases, and two had fewer than 100.

A potential sign the virus isn’t spiking, the state has seen a decrease in the portion of tests performed each day that are positive, a metric that officials have said they would rely on as they increase testing across the state. That measurement is one of the criteria the state should meet before beginning to lift restrictions on businesses, according to White House guidelines.

DHEC officials have not explained to The State how they’re evaluating the daily case count data to issue recommendations.

“In terms of where we are, it seems like the curve has flattened, but we are all a little hesitant to say that the peak of infection is already behind us,” Clemson University associate professor of public health sciences Lu Shi said. “We don’t see the daily death counts substantially declining. We do not see the daily confirmed infections going down substantially. We do not see the pressure on the hospitals substantially dramatically easing.”

“We are not rising, we are not on the uptick, but we are not declining yet,” Shi said.

DHEC officials have admitted that testing data likely has captured only part of the story about how COVID-19 is moving through the state’s communities.

For every person who tests positive for the coronavirus, DHEC estimates there could be up to nine more who have contracted the disease but who have not been diagnosed.

That means labs have not tested thousands of potential coronavirus patients across the state As of May 10, officials estimated that more than 54,600 people across the state have contracted COVID-19, while they had only confirmed 7,653 cases.

DHEC’s estimated case numbers have consistently grown from day to day by anywhere from several hundred to 2,000 per day.

DHEC officials have also said they need more testing in rural and poor areas across the state, many of which do not have ready access to a hospital. This month, they announced a plan to vastly expand testing across the state — a plan they are rolling after retail businesses and restaurants have already been green lighted to reopen and as close contact businesses prepare to reopen next week.

Once social distancing ends

McMaster has continued to express confidence in reopening establishments across the state, citing South Carolinians’ compliance to earlier stay at home orders and social distancing recommendations.

Each time McMaster has taken steps to reopen the state further, DHEC officials have stressed that it’s important to continue practice social distancing despite the availability of businesses.

The health agency continued that message Monday.

“It is most important to pay attention to the social distancing,” Bell said Monday. “Now, we’re saying 10 feet between people, especially if you’re going to be convened for a long period of time.”

Social distancing was key to reducing the spread of the coronavirus, MUSC’s Sweat said. The coronavirus’ sensitivity to people staying at home and limiting their contact with each other was “dramatic” and “profound,” he added.

“As soon as that gets loosened up, we’re going to have to watch real closely what happens because it could very rapidly kick off again,” Sweat said.

But it’s unclear whether state officials have a plan for a resurgence in COVID-19 cases. They have yet to share their plan for how to tackle the likely spike in cases.

During a press conference May 1, McMaster fielded a question about whether he would issue another stay at home order if the coronavirus began to surge in the state again.

“We’ll cross that bridge when we get to it, and we’ll be very careful as we have been,” McMaster said. “We do not expect that to happen.”

On April 20, Bell also addressed the issue.

“We recognize the need to be very, very cautious in relaxing preventive measures so we don’t see a rebound in disease activity,” Bell said.

Large gatherings are of particular concern, health experts say. They can lead to “super spreader” events that can cause cases to grow out of control, Sweat said. For example, in Albany, Georgia, a well-attended funeral lead to 70% of attendees contracting the coronavirus, which quickly spread throughout the community.

“Once you get that many people all of a sudden infected, you really don’t have the capacity to track and trace, and that’s a critical thing when you have an outbreak.,” Sweat said. “You get in there right away, you contact their contacts and you try to test them if you have the capacity.”

South Carolina should also consider taking incremental steps to reopening, both Sweat and Clemson’s Shi said.

Right now, a South Carolina law allows law enforcement to break up groups of three or more people if they are not complying with social distancing recommendations. Shi recommended the state should consider relaxing that regulation to six, then 10, then 20 as they see a gradual decline in cases.

“Its not so much of a … black and white reopen,” Shi said. “Let’s think about different degrees of social distancing so we can gradually relax these regulations and closely watch the trends every step of the way.”

Asked Friday to describe what he would consider an unsafe group, McMaster said law enforcement can use their discretion.

“If law enforcement sees a situation where those rules, those considerations, those courtesies and cares are not being taken, then they can step in and disperse the crowd if necessary,” McMaster said. “We have excellent law enforcement. They’ll know it when they see it, just like you or I would.”

Sweat said there may not be a viable one-size-fits-all approach to reopening the state. Some areas, like Florence County are still experiencing a much more severe outbreak of coronavirus than other areas, like Charleston County, he said.

“Right now, in Florence, I don’t think they should be loosening up,” Sweat said of the Pee Dee county where 444 people have fallen sick and 23 have died as of Monday. “They’re in a state right now where they need to be locked down a little longer to get things under control.”

State officials should be sure to closely measure hot spots around the state for flare ups, and lock those areas down when necessary, Sweat said.

“I think slowly doing this and watching the metrics is really the way to go,” Sweat said. “The hope we all have is we could get back to more normality and keep our eyes on the hot spots and the outbreaks, and when we see them, we kind of lock things down again and adjust until we can get to a place where there is a vaccine.”

Testing, contact tracing key to safe reopening

DHEC officials have announced several initiatives to expand protective bellwethers that would alert them to an outbreak of the virus, but high traffic businesses across the state are already opening.

To be able to quickly ferret out a COVID-19 outbreak, increasing testing is essential, Sweat said. When access to testing is limited, the virus can spread undetected.

“So, people get infected. It takes about 6-14 days for most people to become sick,” Sweat said. “...(I)n those couple of weeks before they get detected, in those two weeks if we have an outbreak, in those two weeks we could have an explosion of an epidemic happening before it was really detected. So, that’s the weakness in our system right now.”

Some research suggests that testing needs to increase to a minimum of 152 people in every 100,000 each day. In South Carolina, that would mean DHEC and private labs would need to complete more than 7,600 tests every day. But when you take in account the Palmetto State’s population density, officials should be aiming for about 1,600 tests per day, experts at Harvard’s Global Health Institute say.

Through May 3, DHEC reported an average of about 1,600 tests being completed each day in South Carolina. In all, about 1.3% of the state’s population have been tested for COVID-19.

DHEC officials have released a plan for increasing testing. Wednesday, officials said they plan to double the amount of testing being done in the state, with a goal of testing about 2% of the state’s total population — or more than 110,000 people — each month.

Another issue is those who are asymptomatic or unable to qualify for testing are still out in the world transmitting the virus, Sweat said.

Between 5% and 80% of patients with COVID-19 are asymptomatic, according to the University of Oxford’s Centre for Evidence-Based Medicine.

“Our ability to sort of have those measures that will tell us when things are going wrong has some weaknesses,” Sweat said. “If we had better testing or if we had testing available on demand, that would help a lot because you would test people before they really got sick.”

But in cases where states or countries don’t have the resources to increase testing, heavy contact tracing can help public health officials efficiently track the progression of the virus, Clemson’s Shi said.

Some countries like Germany and Norway have utilized apps to do contact tracing and to alert residents they had come in contact with someone who tested positive for the coronavirus, Shi said, and the U.S. should consider following their lead.

“If used by a significant portion of their citizens, like 60% … that will make them a lot safer when they tip toe back to reopen their economy,” Shi said.

DHEC officials are working on increasing the state’s ability to contact trace. DHEC has increased its contact tracing staff from 20 to 400 as of Monday, the department announced. The agency also retained 1,400 more contact tracers by contracting with private companies.

“Indicators that are earlier are critical to us moving forward,” Sweat said. “We need better surveillance early on where we do random samples of people to track things. That’s what’s done in most epidemics.”