Phase 2 Is Not Going Well

Jun 18, 2020

It’s been two weeks since Louisiana began Phase 2 of slowly reopening the state, and public health officials are seeing worrying trends.

New coronavirus cases continue to roll in by the hundreds every day, and on Wednesday, the figure was just under 800 — an increase far above the average 512 cases reported daily since June. The health department said 20 more people have died, bringing the total to 2,950.

Then there was another troubling figure: Of all the tests reported that day, 7.4 percent were positive — a rate higher than any day since June 2.

“I think we're certainly worried that we're seeing movement in the wrong direction,” said Dr. Alex Billioux, the assistant secretary for the Louisiana Office of Public Health.

He’s the official who’s almost become a household name thanks to his presence at the governor’s briefings on COVID-19. And in recent weeks, he’s sounded the alarm particularly about a few key regions in the state: the areas around Lake Charles in the southwest, Alexandria in the center of the state, and Monroe in the northeast.

In Monroe, the concern is longstanding. Cases there have been increasing and so have hospitalizations for some time, Billioux said. But that region has also seen some signs of leveling off amid a wave of increased testing.

That’s not true for the Lake Charles and Alexandria regions. Even though testing is also rising there, the percentage of those tests that are positive is rising too — an indicator that the virus is continuing to spread.

“And it's not just cases, we're also seeing hospitalizations go up in those two regions, as well,” Billioux said.

The question is: Why? And one likely answer is that people simply aren’t taking public health measures seriously. They might not be wearing masks or keeping 6 feet of distance from others when they go out.

“We're worried about people starting to feel like COVID is in the past, when COVID is still very much with us, and, frankly, we're seeing signs that are starting to come back in larger numbers,” Billioux said.

These are also parts of the state that weren’t initially hit hard at the outbreak of the pandemic. And there might be cultural or political differences, too, said Susan Hassig, an infectious disease epidemiologist and professor at Tulane University.

“One of the challenges that we've got is understanding what may be regional differences in terms of willingness to engage in the kinds of behaviors that are important to reducing the spread of the virus,” Hassig said.

Billioux is also concerned that outbreaks in bordering states could impact Louisiana, perhaps nowhere more so than in Texas, where cases have spiked dramatically and records for hospitalization have been set this week. It’s not clear how this virus will spread across the region as governments loosen restrictions, interstate travel and trade picks up, and people start traveling between hotspots in different states. But there are signs that what happens across the border impacts Louisiana.

“If you look at Texas, one of the biggest hotspots that they have is [in] Houston,” Billioux said. “And certainly, when we look at what's going on in Region 5 and Lake Charles and Calcasieu and areas around it, we certainly are concerned that that aligns with one of the Texas hotspots.”

He also pointed to ties between an outbreak in Beaumont, Texas, and the Lake Charles area.

Some of Louisiana’s neighboring states should never have opened up, Hassig said. “Texas should never have reopened. Nor should Florida because they never brought their case counts down. Louisiana did.”

But more than viruses cross borders, and that’s Hassig’s primary worry.

“My concern is the behavior of people no matter where they are, whether they're Texans or Louisianans or Floridians are or Arkansans — that if you're in a public space with other people, you should be trying to keep distance and you should be wearing a mask,” she said.

Every place has the virus, and you can’t tell who has it or not.

“It could be you. It could be the person you're standing next to,” she said. “And so I am not so concerned about a permeability of borders and infections moving across, but almost rather attitudes permeating the border.”

“Racism is a public health crisis, full stop.”

As in the rest of the nation, public health officials in Louisiana have also been grappling with how to respond to the wave of massive protests against racism and police violence, and especially how they’re tied to the dramatic racial disparities in cases and deaths of COVID-19.

One way has been to join in. On June 11, Michael Gillette, a doctor at the Veterans Affairs hospital in New Orleans and a clinical instructor at Tulane, was among researchers, physicians and students who held their own protest.

“Racism is a public health crisis, full stop,” Gillette said. “So just as police violence kills

black Americans at a rate three times that of white Americans, you are two to three times more likely to contract COVID and six times more likely to die from COVID compared to white Americans.”

He said the protest’s goal was to spur institutional change to address bias and racism in health care. Everyone wore masks and spread out, many dressed in scrubs and lab coats.

As for whether these protests will play an outsized role in spreading the virus, Billioux said, that’s hard to determine. Jeff Asher, co-founder of AH Datalytics, noted that New Orleans had its highest percentage of positive cases on Wednesday, 4.9 percent, since early May.

But the health department has no indication at this point that protests have caused a spike in cases. For one thing, tracing people connected to a protest is much harder than tracing colleagues at work, for example.

Protests are outside — a key way to diminish contagion. And protesters have often been wearing masks. But hundreds of people have still been bunched together, shouting and singing, or coughing and heaving after being hit with tear gas.

“If I'm trying to decide what's the higher risk to health, being in a casino, indoors, with a mask versus being outdoors, really fighting for civil rights and anti-racism, you know, it's hard for me to say that the protests present a greater risk,” Billioux said.

Contact tracing is only reaching a fraction of people who’ve been sick.

Another worrying trend is how few people who test positive for the virus are actually being reached by contact tracers. These are the people tasked with contacting every single person who tests positive for the virus — and anyone they may have been in close contact with — to encourage them to self-isolate to stop the disease’s spread. And the numbers here aren’t good either.

The department of health only has contact information for about 60 percent of positive coronavirus cases. Contact tracers are only reaching 60 percent of those people. And of the people they do reach, they’re only able to connect with 66 percent of their contacts. At every step, that’s a significant drop.

A recent study by researchers at Harvard University and Standford University found that contact tracing and isolation efforts need to exceed 50 percent just to cut coronavirus cases by 10 percent.

Billioux said other health departments are facing the same kinds of challenges. The department is working to get contact information for all positive cases, and trying to educate the public to pick up their phone when it calls, Billioux said

“Yes, it's voluntary. It's not mandatory. We're not trying to go out and punish people for having COVID, it’s the opposite,” she said. “We’re saying, look, this is the only and best opportunity that we have to do our civic duty to try to stop the spread of COVID and we’re here to help.”

Contact tracing is the key way to cut short a potential outbreak and limit the virus’s ability to spread exponentially, Hassig said.

“It's absolutely critical. Absolutely,” she added. “Because otherwise we could, in relatively short order, find ourselves back in March.”

It’s not clear we’re heading that direction, but it’s also not out of the realm of the possible, especially if we begin to act as if the battle has been won months — or perhaps years — before there’s a vaccine. If you walk into a restaurant and no one’s wearing masks, Billioux said, you should walk out.

“If we don't see better adherence, we don't see cases again begin to decrease rather than start to increase, we're going to be in a bad place,” Billioux said. “And none of us want to go back to stay at home.”