Stay-at-home orders associate with subsequent decreases in COVID-19 cases and fatalities in the United States

  1. James H. Fowler
  2. Seth J. Hill
  3. Remy Levin
  4. Nick Obradovich

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Abstract

Governments issue “stay-at-home” orders to reduce the spread of contagious diseases, but the magnitude of such orders’ effectiveness remains uncertain. In the United States these orders were not coordinated at the national level during the coronavirus disease 2019 (COVID-19) pandemic, which creates an opportunity to use spatial and temporal variation to measure the policies’ effect. Here, we combine data on the timing of stay-at-home orders with daily confirmed COVID-19 cases and fatalities at the county level during the first seven weeks of the outbreak in the United States. We estimate the association between stay-at-home orders and alterations in COVID-19 cases and fatalities using a difference-in-differences design that accounts for unmeasured local variation in factors like health systems and demographics and for unmeasured temporal variation in factors like national mitigation actions and access to tests. Compared to counties that did not implement stay-at-home orders, the results show that the orders are associated with a 30.2 percent (11.0 to 45.2) average reduction in weekly incident cases after one week, a 40.0 percent (23.4 to 53.0) reduction after two weeks, and a 48.6 percent (31.1 to 61.7) reduction after three weeks. Stay-at-home orders are also associated with a 59.8 percent (18.3 to 80.2) average reduction in weekly fatalities after three weeks. These results suggest that stay-at-home orders might have reduced confirmed cases by 390,000 (170,000 to 680,000) and fatalities by 41,000 (27,000 to 59,000) within the first three weeks in localities that implemented stay-at-home orders.

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  1. Version published to 10.1371/journal.pone.0248849
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    SciScore for 10.1101/2020.04.13.20063628: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    NIH rigor criteria are not applicable to paper type.

    Table 2: Resources

    No key resources detected.

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    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    With that said, we note certain limitations in our analysis. Stay-at-home policies are ultimately assigned endogenously so, as with any observational study, we cannot say for certain that the associations we have measured are the result of a causal effect. Our tests of reverse causality suggest that stay-at-home orders influence case growth and not the other way around, but there is no way around the fact that these are observational data from which causal estimates are notoriously difficult to obtain. Our dependent variables -- cases and fatalities -- are based on incomplete data. It is well-known that rates of testing in the United States were extremely low in the early part of the pandemic,2,21 so measures of cumulative cases and fatalities over time probably increased faster than the disease itself due to the addition of previously undetected infections. And many cases and fatalities may have gone undetected entirely. We attempt to control for this issue with county and time fixed effects and a measure of the growth in testing, but we are unlikely to have entirely adjusted for local variation in access to tests. Our independent variable, stay-at-home order status, measures a policy intervention that was often implemented simultaneously or within days of several other local interventions, such as bans on mass gatherings and closures of schools, non-essential businesses, and/or public areas. Given the uncertainty about how many days infected individuals are contagious both ...

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: We did not find any issues relating to colormaps.

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    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
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    • No protocol registration statement was detected.

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  3. Version published to 10.1101/2020.04.13.20063628v3 on medRxiv
  4. Version published to 10.1101/2020.04.13.20063628v2 on medRxiv
  5. Version published to 10.1101/2020.04.13.20063628v1 on medRxiv