Abstract
To cope with the continuing coronavirus disease 2019 (COVID-19) pandemic, state and local officials need information on the effectiveness of policies aimed at curbing disease spread, as well as state-specific characteristics, like the racial mix, associated with increased risks related to the disease. To investigate whether state-imposed stay-at-home orders (SAHOs) and the proportion of African American population in a state were associated with the state-level COVID-19 cases. This cross-sectional study used daily, state-level data on COVID-19 cases, tests, and fatalities from the COVID Tracking Project. Data from March 1 to May 4, 2020, for all states (except Washington state) as well as the District of Columbia were used. The key exposure variables were state-level SAHO (1 if in place, 0 otherwise), and proportion of state population who are African American. The primary outcome was daily cumulative COVID-19 case rates. A secondary outcome was subsequent COVID-19 fatality rates, derived using mean cumulative fatality rates 21 to 28 days after each date. Multivariate regression models were estimated. The final sample included 3023 pooled state- and day-level observations. The mean (SD) cumulative positive case rate was 103.186 (200.067) cases per 100 000 state population, the mean (SD) cumulative test rate was 744.23 (894.944) tests per 100 000 state population, and the mean (SD) subsequent cumulative fatality rate was 12.923 (21.737) deaths per 100 000 state population. There was a negative association of SAHOs with cumulative case rates (β = -1.166; 95% CI, -1.484 to -0.847; P < .001) and subsequent fatality rates (β = -0.204; 95% CI, -0.294 to -0.113; P < .001). Estimation analyses indicated that expected cumulative case rates would have been more than 200% higher and fatality rates approximately 22% higher if there were no SAHOs, as compared with SAHOs fully in place. A higher proportion of African American population was associated with higher case rates (β = 0.045; 95% CI, 0.014 to 0.077; P = .001) and fatality rates (β = 0.068; 95% CI, 0.044 to 0.091; P < .001). In this cross-sectional study, SAHOs were associated with reductions in COVID-19 case rates. These findings could help inform policy makers to address the continued COVID-19 pandemic in the US. The proportion of African American population was positively associated with COVID-19 case rates, and this state-level finding adds to evidence from existing ecological studies using county-level data on racial disparities in COVID-19 infection rates and underlines the urgency of better understanding and addressing these disparities.
Highlights
The coronavirus disease (COVID-19) pandemic has shown little sign of abating in the US
There was a negative association of stay-at-home orders (SAHOs) with cumulative case rates (β = −1.166; 95% CI, −1.484 to −0.847; P < .001) and subsequent fatality rates (β = −0.204; 95% CI, −0.294 to −0.113; P < .001)
A higher proportion of African American population was associated with higher case rates (β = 0.045; 95% CI, 0.014 to 0.077; P = .001) and fatality rates (β = 0.068; 95% CI, 0.044 to 0.091; P < .001)
Summary
The coronavirus disease (COVID-19) pandemic has shown little sign of abating in the US. Mixed messages from political authorities on the policy usefulness, popular pressure, as well as concerns about the economic fallout[2] led some states to lift SAHOs before public health experts considered it advisable. The subsequent increase in infections and fatalities in several states has led some experts to speculate that another round of shutdowns and SAHOs may be necessary to control the disease spread.[3]. One analysis in the Wall Street Journal[4] suggested that SAHOs did not curb COVID-19 fatalities. Subsequent analysis, using small numbers of states, indicated that SAHOs might have helped curb infections and hospitalizations.[5,6] We argue that a more comprehensive assessment of SAHOs that uses information from a wider selection of states will help inform public health experts and federal, state, and local policy makers
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