[Leftcoast]

Santa Clara is to enter Phase 2 reopening per the board of supervisors.  More retail, more manufacturing and logistics, some lightening up on outdoor activities not including playgrounds.

From my Supervisor, Dave Cortese, 

A joint announcement from Bay Area health officers, including Santa Clara County Health Officer Dr. Sara Cody,  was made today, with details released at a  news conference. There was progress made on our indicators: the trend of new cases has been stable or decreasing, even with increased testing; the number of people hospitalized is declining; hospitals are reporting improved supplies of PPEs; and there is increased capacity of case investigation and tracing.

The revised order allows the reopening of retail businesses that can offer storefront pick-up, as well as the resumption of manufacturing, warehousing and logistical operations that support retail. On May 4, construction projects resumed, some recreation activities were permitted, and childcare was provided for essential workers.

https://www.sccgov.org/sites/covid19/Pag...18-20.aspx

[Leftcoast]

Santa Clara is to enter Phase 2 reopening per the board of supervisors.  More retail, more manufacturing and logistics, some lightening up on outdoor activities not including playgrounds.

From my Supervisor, Dave Cortese, 

A joint announcement from Bay Area health officers, including Santa Clara County Health Officer Dr. Sara Cody,  was made today, with details released at a  news conference. There was progress made on our indicators: the trend of new cases has been stable or decreasing, even with increased testing; the number of people hospitalized is declining; hospitals are reporting improved supplies of PPEs; and there is increased capacity of case investigation and tracing.

The revised order allows the reopening of retail businesses that can offer storefront pick-up, as well as the resumption of manufacturing, warehousing and logistical operations that support retail. On May 4, construction projects resumed, some recreation activities were permitted, and childcare was provided for essential workers.

https://www.sccgov.org/sites/covid19/Pag...18-20.aspx

[OutsiderFan]

For me, this is the "money shot" quote from that link:

"evidence of continued significant community transmission of COVID-19 within the County and throughout the Bay Area"

Dr. Cody is effectively saying the same conditions that led to the SIP order still exist based on latest case confirmations. That is they are still getting new infections from people who report no contact with other Covid-positive people. 

Will this ever not be the case? I mean you can't stay sheltered forever. It seems to me NPIs can be put in place to guide businesses and people, but after that, people have to be let loose and then robust contact tracing must be done.

[OutsiderFan]

For me, this is the "money shot" quote from that link:

"evidence of continued significant community transmission of COVID-19 within the County and throughout the Bay Area"

Dr. Cody is effectively saying the same conditions that led to the SIP order still exist based on latest case confirmations. That is they are still getting new infections from people who report no contact with other Covid-positive people. 

Will this ever not be the case? I mean you can't stay sheltered forever. It seems to me NPIs can be put in place to guide businesses and people, but after that, people have to be let loose and then robust contact tracing must be done.

[Goose]

Will this ever not be the case? I mean you can't stay sheltered forever. It seems to me NPIs can be put in place to guide businesses and people, but after that, people have to be let loose and then robust contact tracing must be done.

This is the crux of the problem. It is "OK" (although obviously less than desirable) if there are "a few" cases where the source of the disease is not determinable. However, what is not OK is if there are cases where their contacts are not traced and quarantined as necessary. We are relying on that latter step to replace our complete "semi-quarantine" for everybody. Unfortunately, as of now, I see little evidence that San Mateo County, San Francisco County, and Santa Clara County are doing that, or can do that. The idea that any new or significantly expanded tracing capability could go from a standing start to full speed in a day or so is absurd. They should have been practicing and ramping up during SIP so as it is lifted the Health Departments (and hopefully the public) would know what tracking and tracing capability was actually available and have a good idea what is possible regarding successful containment going forward (hopefully including some surge capacity).

There has been lots of discussion/blame assignments to the Trump administration, China, the CDC, and even some to Newsom. While that is all interesting and important, I am going to assert the following: The County Health Departments have had 60 days to be ready to track and trace. They knew for sure from day one that the removal of SIP was coming at some point. They knew that they were going to be called upon to execute. If they are not ready, and haven't been screaming to the rafters (which they have not), they have NO excuse. I want to see the number of contacts quarantined and the the number of cases who have been successfully traced to their origin on the web county web sites RTFN. It should already be there IMHO. Are we here in the Bay Area actually entering the "wild west" without admitting it, or are we still following what we all thought was the "plan"?

[Goose]

Will this ever not be the case? I mean you can't stay sheltered forever. It seems to me NPIs can be put in place to guide businesses and people, but after that, people have to be let loose and then robust contact tracing must be done.

This is the crux of the problem. It is "OK" (although obviously less than desirable) if there are "a few" cases where the source of the disease is not determinable. However, what is not OK is if there are cases where their contacts are not traced and quarantined as necessary. We are relying on that latter step to replace our complete "semi-quarantine" for everybody. Unfortunately, as of now, I see little evidence that San Mateo County, San Francisco County, and Santa Clara County are doing that, or can do that. The idea that any new or significantly expanded tracing capability could go from a standing start to full speed in a day or so is absurd. They should have been practicing and ramping up during SIP so as it is lifted the Health Departments (and hopefully the public) would know what tracking and tracing capability was actually available and have a good idea what is possible regarding successful containment going forward (hopefully including some surge capacity).

There has been lots of discussion/blame assignments to the Trump administration, China, the CDC, and even some to Newsom. While that is all interesting and important, I am going to assert the following: The County Health Departments have had 60 days to be ready to track and trace. They knew for sure from day one that the removal of SIP was coming at some point. They knew that they were going to be called upon to execute. If they are not ready, and haven't been screaming to the rafters (which they have not), they have NO excuse. I want to see the number of contacts quarantined and the the number of cases who have been successfully traced to their origin on the web county web sites RTFN. It should already be there IMHO. Are we here in the Bay Area actually entering the "wild west" without admitting it, or are we still following what we all thought was the "plan"?

[oldalum]

 Unfortunately, as of now, I see little evidence that San Mateo County, San Francisco County, and Santa Clara County are doing that, or can do that. 

I think we just don't know. Absence of evidence is not evidence of absence. But I think that it's highly unlikely that the public health officers who were so smart and proactive as to lead the nation in flattening the curve suddenly became so dumb as to not appreciate the need to contact trace all positives and to prepare for a surge in contact tracing, and to not appreciate the consequences of being unable to do that. If they're not ready, I doubt it's from lack of knowledge or effort. Until we actually know what is happening with the ramp-up in capability for contact tracing, I am willing to trust that they are continuing to do a good job. YMMV of course.

On the SCC website are 5 indicators to consider when deciding when and how they can relax the restrictions. #4 is:

"Indicator 4: We Have Sufficient Case Investigation, Contact Tracing, and Isolation/Quarantine Capacity

To break chains of transmission, we must rapidly develop the capacity necessary to identify and isolate persons with COVID-19 and those who have been exposed to COVID-19. In communities throughout the Bay Area and around the country, we must do this at an unprecedented scale and speed, many times beyond what public health departments across the country are resourced to do currently. This will require a massive and rapid infusion of resources, including disease investigators, information management tools, and the combination of housing, food, and income-replacement needed to allow infected and exposed community members to isolate themselves from others. This infrastructure must be designed to accomplish the following:

We reach at least 90% of cases and identify their contacts;
We ensure 90% of the cases that we reach can safely isolate;
We reach at least 90% of all contacts identified; and
We ensure at least 90% of identified contacts can safely quarantine."

They also say: "We plan to report publicly on our progress on these local Indicators, so that the community can also track our collective progress." Sure it would be nice to know how close they are to that capability, but they're the ones who set the goal and I bet they're doing their best to meet it.

They also say: "The Indicators are important measures of progress as we assess whether and to what extent we can move away from the existing shelter-in-place restrictions that have been required to slow the spread of the virus. However, other factors will also guide the Health Officers’ decision making, including the development of other methods to contain COVID-19, the impact of the staged reopening of various sectors, the level of compliance with social distancing orders and guidance, collective compliance with isolation and quarantine directives for persons who are infected or exposed, and other scientific developments during this rapidly evolving pandemic. Further, decisions to modify existing restrictions will be made based on the totality of the circumstances; substantial progress on several important Indicators and other factors may allow additional activities to resume even if certain goals within the Indicators have not yet been achieved."

web page

[oldalum]

 Unfortunately, as of now, I see little evidence that San Mateo County, San Francisco County, and Santa Clara County are doing that, or can do that. 

I think we just don't know. Absence of evidence is not evidence of absence. But I think that it's highly unlikely that the public health officers who were so smart and proactive as to lead the nation in flattening the curve suddenly became so dumb as to not appreciate the need to contact trace all positives and to prepare for a surge in contact tracing, and to not appreciate the consequences of being unable to do that. If they're not ready, I doubt it's from lack of knowledge or effort. Until we actually know what is happening with the ramp-up in capability for contact tracing, I am willing to trust that they are continuing to do a good job. YMMV of course.

On the SCC website are 5 indicators to consider when deciding when and how they can relax the restrictions. #4 is:

"Indicator 4: We Have Sufficient Case Investigation, Contact Tracing, and Isolation/Quarantine Capacity

To break chains of transmission, we must rapidly develop the capacity necessary to identify and isolate persons with COVID-19 and those who have been exposed to COVID-19. In communities throughout the Bay Area and around the country, we must do this at an unprecedented scale and speed, many times beyond what public health departments across the country are resourced to do currently. This will require a massive and rapid infusion of resources, including disease investigators, information management tools, and the combination of housing, food, and income-replacement needed to allow infected and exposed community members to isolate themselves from others. This infrastructure must be designed to accomplish the following:

We reach at least 90% of cases and identify their contacts;
We ensure 90% of the cases that we reach can safely isolate;
We reach at least 90% of all contacts identified; and
We ensure at least 90% of identified contacts can safely quarantine."

They also say: "We plan to report publicly on our progress on these local Indicators, so that the community can also track our collective progress." Sure it would be nice to know how close they are to that capability, but they're the ones who set the goal and I bet they're doing their best to meet it.

They also say: "The Indicators are important measures of progress as we assess whether and to what extent we can move away from the existing shelter-in-place restrictions that have been required to slow the spread of the virus. However, other factors will also guide the Health Officers’ decision making, including the development of other methods to contain COVID-19, the impact of the staged reopening of various sectors, the level of compliance with social distancing orders and guidance, collective compliance with isolation and quarantine directives for persons who are infected or exposed, and other scientific developments during this rapidly evolving pandemic. Further, decisions to modify existing restrictions will be made based on the totality of the circumstances; substantial progress on several important Indicators and other factors may allow additional activities to resume even if certain goals within the Indicators have not yet been achieved."

web page

[Goose]

 Unfortunately, as of now, I see little evidence that San Mateo County, San Francisco County, and Santa Clara County are doing that, or can do that. 

I think we just don't know. Absence of evidence is not evidence of absence. But I think that it's highly unlikely that the public health officers who were so smart and proactive as to lead the nation in flattening the curve suddenly became so dumb as to not appreciate the need to contact trace all positives and to prepare for a surge in contact tracing, and to not appreciate the consequences of being unable to do that. If they're not ready, I doubt it's from lack of knowledge or effort. Until we actually know what is happening with the ramp-up in capability for contact tracing, I am willing to trust that they are continuing to do a good job. YMMV of course.

I would generally agree that absence of evidence isn't evidence of absence. I have also exchanged emails with the San Mateo County Health Department, where they assured me that they have been contact tracing 100% of the new cases in the county. They also have said that they are thinking about what statistics they will be sharing about their progress, but that they (understandably) don't want to add too much to their workload.

What worries me is that I haven't heard any reports of anybody being placed in quarantine. Given the howls that normally arise from any restriction on freedoms in the US, if they are quarantining people, I would expect to have heard something about it. So, if they are functioning, I would expect that secondary "evidence" to emerge. I would also expect that it would be wise for the County Health Officers to be preparing the people in their jurisdictions for the somewhat intrusive activities of contact tracers. Going from nothing to lots as a step function would seem unwise as a strategy. You would like to use the positive examples of contact tracing to bring the public along as allies, not opponents. They aren't doing that either.

From what I have read, it takes between 5 and 15 people to support contact tracing of 1 case per day, on average. That would mean San Mateo County would need between 150 people and 450 people to operate on their average of say 30 cases per day. They could have hired/transferred that many people without a big external fuss (and therefore no external evidence). I know that was their original expressed intent. However, I still worry about lack of surge capability (which could require many more people) and any known evidence of activity. In particular, I would expect that contact tracing would reveal important information about why San Mateo County has been stuck in a plateau of cases. Do we have a compliance issue with SIP, is it all healthcare workers, or is it injection from other jurisdictions? Is SFO the problem? So while absence of evidence isn't evidence of absence, at some point the "wake turbulence" of effective enforcement should be visible, even in the absence of full public disclosure. That absence worries me.

[Goose]

 Unfortunately, as of now, I see little evidence that San Mateo County, San Francisco County, and Santa Clara County are doing that, or can do that. 

I think we just don't know. Absence of evidence is not evidence of absence. But I think that it's highly unlikely that the public health officers who were so smart and proactive as to lead the nation in flattening the curve suddenly became so dumb as to not appreciate the need to contact trace all positives and to prepare for a surge in contact tracing, and to not appreciate the consequences of being unable to do that. If they're not ready, I doubt it's from lack of knowledge or effort. Until we actually know what is happening with the ramp-up in capability for contact tracing, I am willing to trust that they are continuing to do a good job. YMMV of course.

I would generally agree that absence of evidence isn't evidence of absence. I have also exchanged emails with the San Mateo County Health Department, where they assured me that they have been contact tracing 100% of the new cases in the county. They also have said that they are thinking about what statistics they will be sharing about their progress, but that they (understandably) don't want to add too much to their workload.

What worries me is that I haven't heard any reports of anybody being placed in quarantine. Given the howls that normally arise from any restriction on freedoms in the US, if they are quarantining people, I would expect to have heard something about it. So, if they are functioning, I would expect that secondary "evidence" to emerge. I would also expect that it would be wise for the County Health Officers to be preparing the people in their jurisdictions for the somewhat intrusive activities of contact tracers. Going from nothing to lots as a step function would seem unwise as a strategy. You would like to use the positive examples of contact tracing to bring the public along as allies, not opponents. They aren't doing that either.

From what I have read, it takes between 5 and 15 people to support contact tracing of 1 case per day, on average. That would mean San Mateo County would need between 150 people and 450 people to operate on their average of say 30 cases per day. They could have hired/transferred that many people without a big external fuss (and therefore no external evidence). I know that was their original expressed intent. However, I still worry about lack of surge capability (which could require many more people) and any known evidence of activity. In particular, I would expect that contact tracing would reveal important information about why San Mateo County has been stuck in a plateau of cases. Do we have a compliance issue with SIP, is it all healthcare workers, or is it injection from other jurisdictions? Is SFO the problem? So while absence of evidence isn't evidence of absence, at some point the "wake turbulence" of effective enforcement should be visible, even in the absence of full public disclosure. That absence worries me.

[OutsiderFan]

This may be a is a massive oversimplification, but it seems to me, based on the totality of information I have synthesized and can consider at the moment, that the best alternative available is this:

Have the Governor, County Health Officers, and Mayors tell people this is still a very dangerous situation. You are very likely to get this virus if you don't stay away from crowds, wear masks, etc. If you are in poor health you want to stay away from others as much as possible.  But even if in relatively good health, if you have bad health insurance coverage and don't want to experience big medical bills as a result of a 2-week hospital stay, you too should avoid others. We'll issue guidelines to businesses to limit infection transmission and will allow them to open, but you take your life and the lives other others you care about in your own hands based on the decisions you make. Act accordingly.

This way you can open things up but basically scare the crap out of people so they won't be as inclined to engage in activities that increase infections and virus spread.  I think we've seen plenty of evidence people just being scared works just about as well as ordinances to keep things shut and people in their homes as much as possible.

Just continue publishing new cases and deaths, show the public where the virus has been detected, and that should go a long way to making people come to the conclusions they need to make. You always get more buy-in when people decide on their own what they are going to do by drawing their own conclusions.

[OutsiderFan]

This may be a is a massive oversimplification, but it seems to me, based on the totality of information I have synthesized and can consider at the moment, that the best alternative available is this:

Have the Governor, County Health Officers, and Mayors tell people this is still a very dangerous situation. You are very likely to get this virus if you don't stay away from crowds, wear masks, etc. If you are in poor health you want to stay away from others as much as possible.  But even if in relatively good health, if you have bad health insurance coverage and don't want to experience big medical bills as a result of a 2-week hospital stay, you too should avoid others. We'll issue guidelines to businesses to limit infection transmission and will allow them to open, but you take your life and the lives other others you care about in your own hands based on the decisions you make. Act accordingly.

This way you can open things up but basically scare the crap out of people so they won't be as inclined to engage in activities that increase infections and virus spread.  I think we've seen plenty of evidence people just being scared works just about as well as ordinances to keep things shut and people in their homes as much as possible.

Just continue publishing new cases and deaths, show the public where the virus has been detected, and that should go a long way to making people come to the conclusions they need to make. You always get more buy-in when people decide on their own what they are going to do by drawing their own conclusions.

[Snorlax94]

 Unfortunately, as of now, I see little evidence that San Mateo County, San Francisco County, and Santa Clara County are doing that, or can do that. 

I think we just don't know. Absence of evidence is not evidence of absence. But I think that it's highly unlikely that the public health officers who were so smart and proactive as to lead the nation in flattening the curve suddenly became so dumb as to not appreciate the need to contact trace all positives and to prepare for a surge in contact tracing, and to not appreciate the consequences of being unable to do that. If they're not ready, I doubt it's from lack of knowledge or effort. Until we actually know what is happening with the ramp-up in capability for contact tracing, I am willing to trust that they are continuing to do a good job. YMMV of course.

I posted on another thread that SCC has updated its page on contact tracing
https://www.sccgov.org/sites/covid19/Pag...acing.aspx

They say they can contact trace 25 cases a day.

SCC got below this level, then has jumped up in recent days, coupled with a dramatic uptick in testing. 

My hope is that the increases are due to contact tracing and that we’re catching more of the cases now, but we don’t know. Maybe it’s more contact tracing, maybe they recently tested some prisons, maybe lots of people were gathering for Mother’s Day, maybe people in SCC are getting lax.

[Snorlax94]

 Unfortunately, as of now, I see little evidence that San Mateo County, San Francisco County, and Santa Clara County are doing that, or can do that. 

I think we just don't know. Absence of evidence is not evidence of absence. But I think that it's highly unlikely that the public health officers who were so smart and proactive as to lead the nation in flattening the curve suddenly became so dumb as to not appreciate the need to contact trace all positives and to prepare for a surge in contact tracing, and to not appreciate the consequences of being unable to do that. If they're not ready, I doubt it's from lack of knowledge or effort. Until we actually know what is happening with the ramp-up in capability for contact tracing, I am willing to trust that they are continuing to do a good job. YMMV of course.

I posted on another thread that SCC has updated its page on contact tracing
https://www.sccgov.org/sites/covid19/Pag...acing.aspx

They say they can contact trace 25 cases a day.

SCC got below this level, then has jumped up in recent days, coupled with a dramatic uptick in testing. 

My hope is that the increases are due to contact tracing and that we’re catching more of the cases now, but we don’t know. Maybe it’s more contact tracing, maybe they recently tested some prisons, maybe lots of people were gathering for Mother’s Day, maybe people in SCC are getting lax.

[BostonCard]

Funny enough, I just found an old hard drive with a presentation I gave to the pulmonary fellows at UCSF back in 2007 about the SARS epidemic.  From my basic epidemiology class:

θ is proportion of transmissions that occur prior to the onset of symptoms
Isolation of symptomatic patients is successful if proportion of patients isolated (ε):ε > (1–1 /R[0])/(1–θ)
Can never be reached if R[0]θ > 1


I think there is evidence that θ is on the order of 50% for COVID-19 (might be as low as 25%, or as high and possibly even higher than 75%).  R[0] is estimated at 2-3, so plugging in 2.5, you get 1.2.  Thus, isolation only of symptomatic patients wouldn't be expected to work, and you are going to have to find and isolate some asymptomatic patients.  Fortunately, you don't have to isolate all asymptomatic patients, just enough to break enough transmission chains to bring R below 1.

BC

[BostonCard]

Funny enough, I just found an old hard drive with a presentation I gave to the pulmonary fellows at UCSF back in 2007 about the SARS epidemic.  From my basic epidemiology class:

θ is proportion of transmissions that occur prior to the onset of symptoms
Isolation of symptomatic patients is successful if proportion of patients isolated (ε):ε > (1–1 /R[0])/(1–θ)
Can never be reached if R[0]θ > 1


I think there is evidence that θ is on the order of 50% for COVID-19 (might be as low as 25%, or as high and possibly even higher than 75%).  R[0] is estimated at 2-3, so plugging in 2.5, you get 1.2.  Thus, isolation only of symptomatic patients wouldn't be expected to work, and you are going to have to find and isolate some asymptomatic patients.  Fortunately, you don't have to isolate all asymptomatic patients, just enough to break enough transmission chains to bring R below 1.

BC

[Goose]

I think there is evidence that θ is on the order of 50% for COVID-19 (might be as low as 25%, or as high and possibly even higher than 75%).  R[0] is estimated at 2-3, so plugging in 2.5, you get 1.2.  Thus, isolation only of symptomatic patients wouldn't be expected to work, and you are going to have to find and isolate some asymptomatic patients.  Fortunately, you don't have to isolate all asymptomatic patients, just enough to break enough transmission chains to bring R below 1.


BC

Yes, and to do that efficiently you will have to isolate some asymptomatic but "probable" contacts of a known positive. That won't go down well with the public at large if it is not properly explained and/or enforced. So far, no evidence of either locally. That worries me a lot, because the Health Officers must know this is an issue.

[Goose]

I think there is evidence that θ is on the order of 50% for COVID-19 (might be as low as 25%, or as high and possibly even higher than 75%).  R[0] is estimated at 2-3, so plugging in 2.5, you get 1.2.  Thus, isolation only of symptomatic patients wouldn't be expected to work, and you are going to have to find and isolate some asymptomatic patients.  Fortunately, you don't have to isolate all asymptomatic patients, just enough to break enough transmission chains to bring R below 1.


BC

Yes, and to do that efficiently you will have to isolate some asymptomatic but "probable" contacts of a known positive. That won't go down well with the public at large if it is not properly explained and/or enforced. So far, no evidence of either locally. That worries me a lot, because the Health Officers must know this is an issue.