As coronavirus projections improve, what will it take for Texas to return to normal?

By at least one metric, Texas had a good weekend.

On Friday, the influential coronavirus model by the Institute for Health Metrics and Evaluation was predicting the state would see 6,392 coronavirus deaths by early August. The state’s peak, the model predicted, would happen on May 6, with 161 Texans dying that day and not enough hospital ICU beds and ventilators available to aid the sickest people.

Those numbers had improved dramatically by Tuesday. Projected deaths had fallen by 68%, to 2,025. The resource peak had been moved up to April 19, with 72 deaths on April 20 and plenty of ICU beds and ventilators available.

Catherine Troisi, an infectious disease epidemiologist at UTHealth School of Public Health in Houston, said the modeling offered a reason to be optimistic but with plenty of caution. The model is based on many assumptions — one of them being that stay-at-home guidelines are being properly followed and that they will be followed through August. Decisions to not follow stay-at-home guidelines would greatly alter the improved scenario.

So when can we consider ending some of the stay-at-home regulations for Texas? What needs to happen before we can peel back the restrictions? And how should Texas and Dallas-Fort Worth go about returning to normal?

Staying home is best option

A natural reaction to potential good news is to relax. We can’t do that yet.

Dennis Perrotta, a retired Texas Department of State Health Services epidemiologist, said models should be treated with caution. And if people were to take anything away from the new projection, he said, it is that staying at home and other restrictions are potentially working: “If we’re seeing the downward trend is true and factual what else could it be that’s doing that other than the public health measures put in place?”

A failure to follow stay-at-home orders now could lead to hospitals becoming inundated with patients and a need to shelter in place again. “I think that as we get further into this stay-at-home order people may get frustrated with it,” Troisi said. “What we might see is an increase after a certain number of weeks and some people going out there.”

William Tierney, chair of the department of population health at the University of Texas’ Dell Medical School, suggested we need to clamp down further. He told Texas Monthly that grocery stores should be closed, and the National Guard should deliver people groceries.

The evidence Texas needs to loosen restrictions

Gov. Greg Abbott’s statewide stay-at-home order lasts until April 30. The same is true for the stay at home orders in Dallas and Tarrant counties. These orders could be withdrawn or extended.

Diana Cervantes, professor of biostatistics and epidemiology at UNT Health Science Center in Fort Worth, said peeling back restrictions will not be a timing decision but made based on evidence that coronavirus can be contained and treated by hospitals and tracked by public health experts. These are some of the signals:

A sustained decline in case numbers: Cervantes said that cases would likely need to decline for weeks, back to a manageable level. Although there is no magic number, the 90 to 100 daily cases that Dallas County has seen recently or the 30 to 60 daily cases in Tarrant County would be too much. “Even if you have 20 to 30 a day, that’s still a lot,” Cervantes said.

A manageable level is one where hospitals could treat coronavirus patients and other emergency patients without running out of equipment or ICU beds. Public health officials also need to be able to use contact tracing to find and isolate people who had been in contact with those who test positive for COVID-19.

The stay-at-home orders in Dallas and Tarrant counties have been in effect for about two weeks. The details of their effect on the number of coronavirus cases won’t be more apparent until the coming days. The long incubation period of COVID-19 (it often takes seven to 14 days for symptoms to appear, plus the lag in test results often take another seven days) means the positive cases announced the last few days are from people who may have been infected two weeks ago or longer.

Better testing: Troisi referred to tests as the eyes of an epidemiologist. “Because we are not testing everybody who should be tested it’s hard to say what’s really happening in the community,” she said.

She said Texas needs to have widespread testing of the most susceptible populations, including health care workers and people who have had contact with those who have tested positive for coronavirus.

To get back to normal, the ideal test would be a blood test that detects whether somebody has antibodies for the coronavirus. “Until we have a test that tells about antibodies and whether you’ve had it in the past then we won’t know who is immune and who is not,” Troisi said. The CDC is in the early stages of testing for coronavirus antibodies.

Improved surveillance beyond testing: Recently, Dallas County and Tarrant County have been releasing statistics that include overall ER admissions, reasons for going to the ER, negative cases and ventilators being used. Cervantes said these numbers need to be considered in addition to the number of coronavirus cases. If a large number of people are still going to the hospital with coronavirus symptoms but not being tested, it’s possible there’s still a high burden of disease that is not showing up in tests, putting society at risk if things went back to normal.

Always a risk: Short of a vaccine or cure, there will be no point in the near future that coronavirus does not pose at least some risk, experts said. Politicians and public health officials will have to decide their acceptable level of risk and how it can be properly mitigated. “Everybody is going to have their own cutoff point — ‘if we hit this number on the way down we’ll allow you to do this,’” Perrotta said. “I just don’t know that we’ll know how to attribute the effectiveness of one specific step (in reducing restrictions) and the number of cases we’re going to prevent.”

And coronavirus may never be gone. “We need to accept in our minds this virus isn’t going to burn off and go away forever,” Cervantes said. “It may be part of our present and our future as a virus that circulates within our population.”

How we’ll start easing back

Getting back to normal will require small steps and waiting to see what happens before making big changes.

Cervantes said one of the first steps could be increasing the number of people who can go to work from critical businesses to important but less essential businesses. When restaurants and stores open, Troisi said Texas may consider limiting occupancy levels to well below half of their normal occupancy. “And if the number of cases don’t go up, you open something else,” she said.

Public health officials will have to spend time studying the effects of every decision. If cases go back up after restrictions are loosened — a second wave of disease — they’ll have to evaluate whether we need to shut down again.

This story was originally published April 8, 2020 at 6:00 AM.