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Variation Among Public Health Interventions in Initial Efforts to Prevent and Control the Spread of COVID-19 in the 50 States, 29 Big Cities, and the District of Columbia

Fraser, Michael R. PhD, MS, CAE, FCPP; Juliano, Chrissie MPP; Nichols, Gabrielle MSPH

Author Information
Journal of Public Health Management and Practice: January/February 2021 - Volume 27 - Issue - p S29-S38
doi: 10.1097/PHH.0000000000001284
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Abstract

As a novel coronavirus, there are no medical countermeasures to prevent transmission of SARS-CoV-2 (COVID-19). Instead, controlling the spread of COVID-19 has depended to date upon individual compliance with recommended nonpharmaceutical interventions (NPIs) such as wearing masks, practicing “good” hand and cough hygiene, and staying 6 ft apart from others, as well as the introduction of and compliance with community-level NPIs to prevent and limit COVID-19 transmission (stay-at-home orders, business closures, travel restrictions, etc).1,2 While hopes for a vaccine to immunize against COVID-19 infection are high, the multiple “Operation Warp Speed” (OWS) vaccine candidates are still being clinically tested and will most likely not be available until spring 2021 at the earliest.3,4 This suggests that effective public health measures to control the spread of COVID-19 will continue to rely on individual- and community-level NPIs for some time, especially as the OWS target efficacy for COVID-19 vaccines is 50%.5 As such, understanding the varying ways NPIs were implemented by states and big cities will inform COVID-19 control efforts in the future.

Policy change in public health practice is an effective way to achieve disease prevention at significant scale in a population. For example, smoking bans in indoor spaces and price increases on tobacco have led to historic lows in tobacco use and related disease burden.6,7 Seat belt laws reduced traffic fatalities by more than 45% since their introduction in the United States in the 1980s.8 The national response to COVID-19 highlights not only the importance of policy levers but also the variation in state and local public health agency responses to NPI implementation and the ways that many jurisdictions adopted, adapted, and innovated various NPIs to fit specific social and political contexts.

A major finding of our research is that even seemingly similar types of NPIs, such as “gathering restrictions,” had extremely different characteristics when first implemented across the country. We found that in some states, cities acted earlier to implement NPIs locally before statewide adoption. There were also numerous differences in NPI implementation between US regions. Highlighting this variation, and the staggered timeline of NPI response, helps anticipate challenges in future planning for COVID-19 mitigation and containment, as well as potential application to other communicable disease responses to other diseases including pandemic influenza or Ebola virus disease.

In this analysis, we examined 3 NPIs used to prevent and control COVID-19 infection and transmission in the initial stage of the United States' response (January 20, 2020, through August 10, 2020). These include mandated use of masks, gathering restrictions, and stay-at-home/shelter-in-place orders. These NPIs were generally implemented by local and state public health authorities, though were not the only NPIs used by states and big cities (see Table 1), and certainly not implemented without controversy and criticism because of their impact on daily activities and the economy.9–11

TABLE 1 - State Use of Nonpharmaceutical Interventions to Prevent and Control COVID-19a
Category Intervention # of States (n = 51)b % of States
Shelter in place/stay home Stay at home/shelter in place 40 78
Religious gatherings exempt without clear social distance mandate 16 31
Physical/social distance closures Closed K-12 schoolsc 50 98
Closed day cares 15 29
Banned visitors to nursing homes 31 61
Closed nonessential businesses 46 90
Closed restaurants except takeout 50 98
Closed gymsd 49 96
Closed movie theaters 49 96
Closed bars 50 98
Use of masks Mandate face mask use by all individuals in public spaces 35 69
Face mask mandate enforced by fines 11 22
Face mask mandate enforced by criminal charge/citation 8 16
No legal enforcement of face mask mandate 32 63
Mandate face mask use by employees in public-facing businesses 44 86
Interstate traveler restrictions Mandate quarantine for those entering the state from specific states 16 31
Mandate quarantine for all individuals entering the state from another state 13 25
Gathering restrictions Order limiting size of gathering 48 94
aFrom Raifman et al.12
bWashington, District of Columbia, was included as a state in this analysis.
cDid not require executive order if department of education closed all public schools; private schools may or may not be included.
dThis column applies to specific orders closing gyms. Many policies closing nonessential businesses also closed gyms.

Gathering restrictions, stay-at-home orders, and face-covering mandates were selected for this analysis but represent only 3 of a much larger group of additional NPIs implemented by states and big cities (see Tables 1 and 2).

TABLE 2 - State and Big City Use of Nonpharmaceutical Interventions to Prevent and Control COVID-19a
Category Intervention State Mandate in Placeb # of BCHC (n = 29) % of BCHC
Shelter in place/stay home Stay at home/shelter in place 23 17 59
Physical/social distance closures Closed K-12 schoolsc 23 19 66
Closed nonessential businesses 28 18 62
Closed restaurants except takeout 29 21 72
Closed gyms 29 21 72
Closed movie theatersd 29 19 66
Closed bars 29 21 72
Use of masks Mandate face mask use by all individuals in public spaces 26 23 79
Mandate face mask use by employees in public-facing businesses 28 23 79
Interstate traveler restrictions Mandate quarantine for those entering the city from specific states 4 2 7
Gathering restrictions Order limiting size of gathering 29 21 72
Abbreviation: BCHC, Big Cities Health Coalition.
aFrom the BCHC internal database.
bWashington, District of Columbia, not included as a city, is in state analysis.
cMaybe due to state order. If explicitly due to state order, not included.
dBased on closure of large entertainment venues.

These 3 NPIs were selected because of their broad adoption nationwide as well as our ability to efficiently obtain the data necessary to examine the details of state and local regulations and mandates in both states and large cities without having to survey extremely busy health officials and their teams. As such, we relied upon secondary data sources on state NPIs and a review of member policies of the Big Cities Health Coalition (BCHC) which comprises 30 of the largest urban health agencies in the United States (see Table 3).12

TABLE 3 - Big Cities Health Coalition Members by HHS Region and Statea
HHS Region State City (County or Health District)
1 & 2 Massachusetts Boston
New York New York City
3 District of Columbia Washington, District of Columbiab
Maryland Baltimore
Pennsylvania Philadelphia
4 Florida Miami (Miami-Dade County)
North Carolina Charlotte (Mecklenburg County)
5 Illinois Chicago
Indiana Indianapolis (Marion County)
Michigan Detroit
Minnesota Minneapolis
Ohio Cleveland
Columbus
6 Texas Austin
Dallas (Dallas County)
Fort Worth (Tarrant County)
Houston
San Antonio
7 Missouri Kansas City
8 Colorado Denver
9 Arizona Phoenix (Maricopa County)
California Oakland (Alameda County)
Long Beach
Los Angeles (County)
San Diego (County)
San Francisco
San Jose (Santa Clara County)
Nevada Las Vegas (Southern Nevada Health District)
10 Oregon Portland (Multnomah County)
Washington Seattle (Seattle-King County)
Abbreviations: BCHC, Big Cities Health Coalition; HHS, US Department of Health and Human Services.
aFrom HHS Regions from https://www.hhs.gov/about/agencies/iea/regional-offices/index.html and BCHC membership from BCHC staff.
bWashington, District of Columbia, is a BCHC member, but for this analysis will be counted as a state.

Variation in policy implementation is a common feature of American democracy, where states and big cities often serve as “laboratories of democracy” to test or assess novel solutions to address specific local or regional problems. Decisions to implement recommended NPIs, such as stay-at-home orders, were extremely political. Public health authorities' and elected leaders' decision making often interrupted the normal day-to-day functioning of society and had massive economic and social impact, contributing to a severe national economic recession.13 In a country as large and diverse as the United States, there were many different ways that governors, mayors, county executives, and other leaders embraced recommendations of local, state, or federal public health officials, opted to modify them, or declined to accept them. The media coverage of health officials' resignations and terminations during COVID-19, as well as public protests against public health and elected officials' orders and mandates, illustrates just how intensely political and divisive decisions to implement various NPIs can be.14,15

Methods and Data

Data on NPI frequency in states and the District of Columbia came from a compilation of state policies conducted by researchers at the Boston University School of Public Health that analyzed multiple sources of publicly available information to verify each state's implementation of various NPIs including state-level orders and mandates.12 Data on 29 big cities came from a database maintained by staff at BCHC, a membership organization representing 30 city health departments in the United States. The variance between BCHC's total 30 members and the 29 represented in these data is due to the fact that the District of Columbia is a federal district, distinct from a state, but for the purposes of its COVID-19 response, functions like a state. District of Columbia, as a member of both BCHC and the Association of State and Territorial Health Officials (ASTHO), is generally funded like a state for public health activities and was included in the Boston University state data set. For all of these reasons, we chose to include it as a state in the analysis, leading to a total of 51 states and 29 big cities.

States and cities were categorized by regions of the country based on the US Department of Health and Human Services (HHS) Regions (see Table 3). Regions 1 (New England states) and 2 (New York and New Jersey) that are treated separately by HHS were combined into one Region (Region 1&2) because HHS Region 2 includes 2 territories (Puerto Rico and the US Virgin Islands) that were not included in this analysis. Frequency distributions were used to compare differences between states by region, between BCHC health departments, and between state and BCHC health departments.

Results

Stay-at-home/shelter-in-place orders

Stay-at-home/shelter-in-place orders broadly restrict individuals from leaving their homes except to perform essential functions, but the details of these orders varied in terms of what functions and which workers were deemed “essential.”12 The National Conference of State Legislatures (NCSL) reviewed state definitions of essential workers and found that of the 42 states with essential worker directives, 20 use the federal Cybersecurity & Infrastructure Security Agency (CISA) classification.16 NCSL notes that the additional 22 states that defined essential workers created state-specific lists that varied in what jobs were included but did include similar workforce sectors such as energy, child care, water and wastewater, agriculture and food production, critical retail (ie, grocery stores, hardware stores, mechanics), critical trades (construction workers, electricians, plumbers, etc), transportation, and nonprofits and social service organizations.16 Notably, in August 2020, the federal government added “teachers” to the national list of essential workers to promote school reopening.17 Forty-nine states allowed alcohol/liquor stores to remain open, and 44 states allowed firearm sellers to remain open, suggesting these retailers were also deemed “essential” by most states.12 Big city data on essential functions and workers definitions as well as local alcohol and firearm sales were not collected.

In the time period of our review (January 20, 2020, through August 10, 2020), 78% of states mandated a stay-at-home order (40 of 51 states) and 59% (17 of 29 cities) of BCHC cities did the same. Some cities did not issue stay-at-home orders because either their states preempted their authority to do so or the comprehensive nature of the state order negated the need for additional local restrictions (see Table 4). The first stay-at-home order was issued by a group of counties in the Bay Area of California on March 16, 2020.18 The first state order was introduced on March 19, 2020, and the last state to introduce an order did so on April 7, 2020. In the BCHC cities that introduced stay-at-home orders, the last city issued its first order on March 26, 2020. In some cities, no stay-at-home order was issued locally because of statewide orders (Regions 1, 2, and 10).

TABLE 4 - Statewide and Big City Shelter-in-Place/Stay-at-Home Mandatesa
HHS Regions States BCHC Member Cities
# of States in Region # With Mandateb % of Region Date of First Implementation Date of Last Implementation # BCHC in Region # BCHC With Mandate State Has Mandate % of Region BCHC With Mandate Date of First Implementation Date of Last Implementation
All states 51c 40 Mar 19, 2020 Apr 7, 2020 29 17 23 Mar 16, 2020 Mar 26, 2020
Region 1&2 (CT, ME, MA, NH, NY, RI, VT) 8 7 88 Mar 21, 2020 Apr 2, 2020 2 0 2 0 n/a n/a
Region 3 (DE, DC, MD, PA, VA, WV) 6 6 100 Mar 24, 2020 Apr 1, 2020 2 1 2 50 Mar 23, 2020 Mar 23, 2020
Region 4 (AL, FL, GA, KY, MS, NC, SC, TN) 8 7 88 Mar 30, 2020 Apr 7, 2020 2 2 1 100 Mar 26, 2020 Mar 26, 2020
Region 5 (IL, IN, MI, MN, OH. WI) 6 6 100 Mar 21, 2020 Mar 28, 2020 6 1 6 17 Mar 21, 2020 Mar 21, 2020
Region 6 (AR, LA, NM, OK. TX) 4 2 50 Mar 23, 2020 Mar 24, 2020 5 5 0 100 Mar 23, 2020 Mar 24, 2020
Region 7 (IA, KS, MO, NE) 5 2 40 Mar 30, 2020 Apr 6, 2020 1 1 1 100 Mar 24, 2020 Mar 24, 2020
Region 8 (CO, MT, ND, SD, UT, WY) 6 2 33 Mar 26, 2020 Mar 28, 2020 1 1 1 100 Mar 24, 2020 Mar 24, 2020
Region 9 (AZ, CA, HI, NV) 4 4 100 Mar 19, 2020 Mar 31, 2020 8 6 8 75 Mar 16, 2020 Mar 24, 2020
Region 10 (AK, ID, OR, WA) 4 4 100 Mar 23, 2020 Mar 28, 2020 2 0 2 0 n/a n/a
Abbreviations: BCHC, Big Cities Health Coalition; HHS, US Department of Health and Human Services.
aFrom Raifman et al12 and the BCHC internal database.
bBoston University researchers recorded guidance or encouragement but not a mandate or order to stay at home as the absence of an order or directive.
cAll states included Washington, District of Columbia (n = 51).

In addition to state and local variations in terms of date of implementation, there were also regional differences. All states in Regions 3 (Mid-Atlantic), 5 (Great Lakes), 9 (West Coast and Hawaii), and 10 (Pacific Northwest and Alaska) implemented stay-at-home orders. Half or less than half of the states in Regions 6 (Gulf Coast), 7 (Heartland), and 8 (Great Plains) implemented stay-at-home orders. All BCHC health agencies had stay-at-home/shelter-in-place orders in regions where not every state had implemented the same (Regions 4, 6, 7, and 8).

Face-covering mandates

In early April 2020, the Centers for Disease Control and Prevention (CDC) recommended the universal use of masks to help reduce the risk of COVID-19 transmission. In this analysis, we included states and big cities with mandates that required use by all individuals in public spaces. The definition of “face mask” was broad in most jurisdictions and included both surgical masks and cloth masks such as bandanas, gaiters, and handkerchiefs in many state and local jurisdictions.19,20 Many states mandated use among essential workers in public-facing businesses (44 of 51 states, or 86% of states), and many of these were issued prior to statewide mandates that applied to use by the general public.12 Enforcement of these mandates was not assessed in this analysis but did vary between local areas within states, and between states, as well as changed over time, and is certainly a topic for future exploration by public health leaders and policy makers.

Early in the COVID-19 response, guidance changed with evolving knowledge about COVID-19 transmission. Unfortunately, mandates became extremely polarizing and politicized, leading to claims of “medical tyranny” by opponents of masking, public demonstrations against health officials mandating their use, and some state and local leaders refusing to require them.15 Despite the wide media coverage of the polarization and politicization of mask use and other NPIs, CDC research on public attitudes toward the use of masks indicated broad public support and adherence to use and stay-at-home orders.21

Use orders for the general public were common but far from universal across the states: 69% of states issued a mandate (35 of 51 states) and 79% of all BCHC cities (23 of 29 cities) did so. All 6 BCHC jurisdictions without local mandates are in states with statewide mandates and as such all BCHC cities implemented masks by local order, in compliance with state orders, or both (see Table 5). There was also an extremely wide range in date of first implementation of a mandate: the first state mandate was issued on April 8, 2020, and the last state mandate on August 5, 2020. This 4-month span may be indicative of the variation in COVID-19 positivity rates across different regions of the country, as well as political debates about the efficacy of a mandate without enforcement and/or the role of government to issue such a mandate at all. Mandates were issued by 50% or fewer states in Region 4 (4 of 8 states), Region 10 (2 of 4 states), Region 8 (2 of 6 states), and Region 7 (1 of 5 states). BCHC cities mandated use before statewide mandates in 5 of the 9 regions (56%) in this analysis. BCHC cities also mandated use in regions where not all states required them (Regions 4, 7, and 8).

TABLE 5 - State and Big City Mandated For Use by All Individuals in Public Spaces by Regiona
HHS Regions States BCHC Member Cities
# States in Region # States With Mandate % of Region Date of First Implementation Date of Last Implementation # BCHC in Region # With Mandate State Has Mandate % of Region Date of First Implementation Date of Last Implementation
All states 51b 35 Apr 8, 2020 Aug 5, 2020 29 23 26 Apr 9, 2020 Jul 10, 2020
Region 1&2 (CT, ME, MA, NH, NY, RI, VT) 8 7 88 Apr 8, 2020 Aug 1, 2020 2 0 2 0 n/a n/a
Region 3 (DE, DC, MD, PA, VA, WV) 6 6 100 Apr 17, 2020 Jul 7, 2020 2 2 2 100 Apr 15, 2020 Jun 26, 2020
Region 4 (AL, FL, GA, KY, MS, NC, SC, TN) 8 4 50 May 11, 2020 Aug 5, 2020 2 2 1 100 Apr 9, 2020 Jun 23, 2020
Region 5 (IL, IN, MI, MN, OH. WI) 6 6 100 Apr 27, 2020 Aug 1, 2020 6 4 6 67 May 26, 2020 Jul 9, 2020
Region 6 (AR, LA, NM, OK. TX) 4 4 100 May 15, 2020 Jul 20, 2020 5 5 5 100 Apr 20, 2020 Jun 25, 2020
Region 7 (IA, KS, MO, NE) 5 1 20 Jul 3, 2020 n/a 1 1 0 100 Jul 10, 2020 n/a
Region 8 (CO, MT, ND, SD, UT, WY) 6 2 33 Apr 10, 2020 Jul 16, 2020 1 1 1 100 Apr 17, 2020 n/a
Region 9 (AZ, CA, HI, NV) 4 3 75 Apr 16, 2020 Jun 26, 2020 8 7 7 88 Apr 15, 2020 Jun 19, 2020
Region 10 (AK, ID, OR, WA) 4 2 50 Jun 26, 2020 Jul 1, 2020 2 1 2 50 May 18, 2020 n/a
Abbreviations: BCHC, Big Cities Health Coalition; HHS, US Department of Health and Human Services.
aFrom Raifman et al12 and the BCHC internal database.
bAll states included Washington, District of Columbia (n = 51).

Gathering restrictions

Gathering restrictions were another significant NPI used in the initial stages of the COVID-19 response, both before and after stay-at-home orders, including limits on the size of groups that could gather in various indoor and outdoor venues and public spaces. Despite any definitive scientific evidence on exactly what is the maximum group size for COVID-19 prevention, both large events and small gatherings have facilitated transmission and common practice has become that gatherings with as few nonhousehold members as possible is best.8 Gathering restrictions were implemented in 48 of the 51 states at some point in the period under study (94%) and 21 of the 29 BCHC jurisdictions (76%) (see Table 6).

TABLE 6 - State and Big City Gathering Restrictions by Regionsa
HHS Regions States BCHC Member Cities
# of States # With Mandateb % of Region # BCHC in Region # With Mandatec % of Region
All states 51d 48 29 21
Region 1&2 (CT, ME, MA, NH, NY, RI, VT) 8 8 100 2 1 100
Region 3 (DE, DC, MD, PA, VA, WV) 6 6 100 2 2 100
Region 4 (AL, FL, GA, KY, MS, NC, SC, TN) 8 8 100 2 2 100
Region 5 (IL, IN, MI, MN, OH, WI) 6 6 100 6 2 33
Region 6 (AR, LA, NM, OK, TX) 4 3 75 5 5 100
Region 7 (IA, KS, MO, NE) 5 4 80 1 1 100
Region 8 (CO, MT, ND, SD, UT, WY) 6 5 83 1 1 100
Region 9 (AZ, CA, HI, NV) 4 4 100 8 6 75
Region 10 (AK, ID, OR, WA) 4 4 100 2 1 50
Abbreviations: BCHC, Big Cities Health Coalition; HHS, US Department of Health and Human Services.
aFrom Raifman et al12 and the BCHC internal database.
bBoston University researchers recorded guidance or encouragement but not a mandate or order to stay at home as the absence of an order or directive.
cAs some BCHC members have multijurisdictional orders (ie, county or city), a mandate was included if either the county or major big city has restriction in place.
dAll states included Washington, District of Columbia (n = 51).

In the regions without 100% implementation by states (Regions 6, 7, and 8), BCHC cities had 100% implementation, further illustrating that local jurisdictions may act in the absence of statewide policy. At the same time, in regions where BCHC cities had less adoption (Regions 4, 9, and 10), the states in those regions had 100% adoption, indicating that local government did not need to act independently because cities were included in the statewide orders.

In BCHC cities, where allowed by state law, local officials often put in place more restrictive gathering limitations than their states: 21 of 29 (72%) BCHC members did so at some point between March and August 2020. For those cities that did not implement such restrictions, some were preempted from doing so while others were aligned with state regulations. Still others had restrictions in place compared with other areas of the state due to phased reopening approaches.

Comparing gathering restrictions between states and local areas demonstrates just how varied the specific scope of an NPI can be when introduced in a state or local jurisdiction. Gathering sizes ranged from permitting only members of one's immediate household to 10, 50, or 250 individuals or larger groups in some states. Places of worship were exempted from restrictions in some states, and some orders allowed them only if social distance could be maintained. In May 2020, the US Supreme Court upheld the state of California's right to restrict worship activities at the South Bay United Pentecostal Church in Chula Vista, California, finding that the state did not, in fact, single out this or any place of worship.22 This ruling supported efforts by local and state officials to restrict even religious gatherings to prevent COVID-19 transmission and demonstrates the controversy and concern around many community NPIs.

Summary of NPIs by region

While the list of NPIs is quite extensive (Table 1), in our analysis of just 3, only 2 regions – Regions 3 (Mid-Atlantic) and 5 (Great Lakes) – had adoption of all 3 NPIs across all states in each region. All states in Regions 9 (Pacific) and 10 (Pacific Northwest and Alaska) adopted 100% of at least 2 of the 3 NPIs we examined. In 3 regions (Regions 1&2, 4, and 6), states adopted 100% of one of the NPIs we examined, and in 2 regions (Regions 7 and 8), 100% of states adopted none of the 3. This again emphasizes the various ways that state and local public health officials, elected leaders, and the public supported and opposed the introduction of various NPIs, especially early in the pandemic when there were different burdens of infection between the coasts of the country, the south, and the mountain regions.

Discussion and Conclusion

Several findings emerge from our review of state and local implementation of 3 specific NPIs. First, NPI implementation varied widely in terms of the timing of the introduction of each NPI in the study. Usually, stay-at-home/shelter-in-place orders or gathering restrictions were first or second and then masks followed. In several cases, big cities introduced stay-at-home restrictions prior to statewide mandates, as they often did with masks as well. Some cities did not implement NPIs initially due to state preemption (eg, in Texas) or because state restrictions were comprehensive and local officials did not deem additional restrictions necessary (eg, New York and Massachusetts). As COVID-19 response continues, big cities may act if they disagree with the relaxing of statewide restrictions or if a state allows more restrictive local regulation.23

Several jurisdictions within California provide an example of local health agencies moving to implement NPIs prior to statewide action. Local health officers in the state have a great deal of legal authority to protect the public's health, and early in the response (March 16, 2020), Bay Area counties collaborated to introduce a regional shelter-in-place order that was the nation's first such move in response to COVID-19.18 Later, as COVID-19 cases expanded across the state, the governor issued a statewide order that preempted counties from introducing orders that were less restrictive than the state's.24 The lack of a uniform statewide approach led to confusion among the public, an experience not unique to California and an important lesson learned for policy makers and for communication in future responses.

Second, in some states, governors preempted local jurisdictions from introducing orders that were more restrictive than the state's order. For example, in Texas, the governor initially prohibited several metropolitan areas from extending local stay-at-home orders and/or mandating public use of masks.25 Only after political pressure and negotiations between local and state leaders did the governor then permit local health authorities to extend their use of several NPIs to prevent and control COVID-19 transmission in their cities.23 Conflict between state and local authorities came to a head in the state of Georgia, where Governor Kemp sued Atlanta Mayor Keisha Lance Bottoms for issuing a mandate that went against state policy.26 After several weeks, the suit was dropped and Mayor Bottoms' order was maintained.26

A third theme that emerged from this research is the wide variation among geographic regions of the United States in state and local implementation of NPIs in the initial stages of the response. All states in just 2 of 9 regions (Regions 3 and 5) implemented all NPIs examined in this review. There were 2 main reasons for this variation. First, in some low-population areas, including predominantly rural/frontier states, there was extremely limited COVID-19 transmission early in the pandemic.27 It was only after large-scale outbreaks in specific industries such as fishing or meat packing that COVID-19 began to spread rapidly in these areas and stay-at-home orders were implemented.28 Second, there were areas of the country that did not want to implement NPIs for economic and political reasons. For example, several governors relaxed statewide stay-at-home orders soon after their implementation and did not require mask use after the May 2020 federal Memorial Day holiday to encourage regional tourism and spur economic recovery. These decisions led to regional viral transmission and COVID-19 “hot spots” in Sunbelt states throughout June, July, and August 2020.

Limitations

Limitations of our study include that the large urban areas in the data were BCHC members and may not be reflective or representative of all large urban centers in the United States. Limitations regarding a lack of a national data set of local policies led us to compare only the NPIs for which we had data in both the BCHC database and the Boston University data set. Another limitation is that the implementation and adoption of these NPIs constantly changes over time; as a result, we included only the NPIs that were initially introduced by the state or local jurisdictions during the initial response to COVID-19 and we did not track any single jurisdiction's multiple implementations over time; for example, a jurisdiction that had a stay-at-home order, relaxed it, and then implemented it again.

Furthermore, while the HHS regions represent valid subgroups of states for comparative purposes, they do vary by the number of states in each region. The states within any given HHS region may have more in common with states in other regions rather than the region to which they are assigned. Furthermore, cities are not generally categorized into regions, but we assigned them to the region of their state for the purposes of this analysis. In addition, the combination of Regions 1 and 2 (Region 1 & 2), classification of DC data with the “state” data, and exclusion of 2 territories in Region 2 may affect interpretation.

Frequency distributions are presented, but no tests of significance were used to assess the statistical significance between them. As such, we offer comparisons that may or may not be statistically significant but are illustrative of differences between regional groupings of states and between states and big city health departments. Further research is needed to validate the themes and trends that emerged from this research using more advanced analytical and statistical methods, as well as more uniform definitions of NPIs across states and cities.

Finally, while not analyzed in the current research, it is important to consider compliance with and enforcement of public health regulations and guidance as we consider how best to continue to slow the spread of COVID-19. Enforcement of stay-at-home/shelter-in-place orders was not assessed in this analysis and is deserving of future attention by policy makers and researchers. Current research has looked at compliance with and public support for NPIs: a recent CDC study found that more than 80% of respondents in New York City and Los Angeles, and in the nation as a whole, supported stay-at-home orders, social distancing guidance, and mask mandates in May 2020.21 One of the many challenges in the US response was the varying degree to which different members of the public adhered to public health orders and complied with NPIs, not just their implementation at the policy level. These challenges to public health authority were not as common in other countries as they were in the United States.

Implications for Policy & Practice
  • An analysis of state and big city adoption of 3 evidence-based nonpharmaceutical policies (gathering restrictions, stay-at-home orders, and mask mandates) highlighted variation in implementation by region of the United States, by date of first implementation, and by how big cities and state public health authorities are delegated in a state.
  • Local and state preemption of authority is important to consider as some big cities had more restrictive community NPIs than states, leading to conflicts around local and state decision making in some areas.
  • This variation should be expected and anticipating variation in planning efforts will help prepare public health leaders and elected officials for future decision making and planning for community mitigation and containment.
  • Regardless of availability of a vaccine or therapeutics for COVID-19, NPIs will still represent one of the most effective ways to prevent or reduce COVID-19 transmission. Their varied adoption in different geographic regions across the country should be used to better understand how to best coordinate NPI implementation in future regional and national outbreaks.

Conclusion

Several findings emerged from this research. First, we found that in some states, cities acted earlier to implement NPIs locally before statewide adoption. We also found that there were many differences in NPI implementation within and between US regions. Highlighting this variation, and the staggered timeline of NPI response, is important to anticipating challenges in future planning for COVID-19 mitigation and containment.

References

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14. Public health officials discuss why they quit during the COVID pandemic. Transcript. Morning Edition. National Public Radio. August 6, 2020. https://www.npr.org/2020/08/06/899679894/public-health-officials-discuss-why-they-quit-during-the-COVID-pandemic. Accessed August 25, 2020.
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Keywords:

big city health departments; COVID-19; nonpharmaceutical interventions; public health policy; state and territorial health departments

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