As Maine residents begin to take advantage of slightly relaxed restrictions, data from multiple sources show that Maine’s battle against coronavirus is trending in the right direction.
Maine’s per capita infection rates are among the lowest in the nation and deaths per 100,000 are in the lower tier. Also, a closely watched disease transmission rate, or “reproduction number,” suggests that Maine is approaching levels needed to begin reducing infections.
But the Mills administration is warning that restrictions will be reimposed if the trend shifts upward again. And public health experts caution that progress could be quickly lost even in rural states like Maine amid attempts to revive the virus-stricken economy.
“I do think, though, that there is a risk that things could change as the weather improves, things start to reopen and people start to show up” in tourist areas, said Stephanie Tomlin, a health data analyst at Dartmouth College.
This weekend, for the first time in a month, Maine residents can visit their barber or hairdresser, hike in a state park, play a round of golf (regular or disc) or reschedule that minor medical procedure for a nagging but not life-threatening ailment.
Gov. Janet Mills included those slightly lessened restrictions as part of Stage 1 in her administration’s multi-month plan to gradually – too gradually, some say – reopen Maine’s economy.
Whether Maine progresses to Stage 2 on June 1 – allowing access to a wider array of retailers as well as restaurants and fitness centers – or Mills reimposes tighter restrictions depends on the daily numbers and longer trend lines of the virus.
“If the Maine (Center for Disease Control and Prevention) detects any resurgence of the virus, we will move quickly to halt progression through the stages and reimplement restrictions to protect your health and safety,” Mills said Tuesday when announcing the phased reopening plan.
Data from multiple sources suggest that Maine is trending in the right direction on many measures, although the state’s low numbers of COVID-19 cases and deaths, at least relative to elsewhere, mean day-to-day fluctuations can affect those trajectories.
“It can change it significantly,” Dr. Nirav Shah, director of the Maine CDC, said in an interview Friday.
COVID ‘REPRODUCTION’ RATE
One metric that the Maine CDC and other public health agencies worldwide track closely is the person-to-person transmission rate, known as the “reproduction number,” also called R, R0 or R-naught.
The intensity and speed of an outbreak is linked directly to how many other people the average sick person will infect. A reproductive number, or R, of 1 means one person will only infect one other person while contagious, while an R of 3 means every infected person will infect three people. And the difference between the two is the difference between a slow, relatively controlled spread and uncontrolled, exponential growth.
To explain the difference, Shah tapped a common grammar school mathematical question: would you rather have $1 million or a penny today that will double every day for a month? That first penny will be worth just $163.84 on Day 15 but, because of exponential growth, would grow to more than $5.3 million by Day 30.
The goal, Shah said, is to get the R below 1 – meaning each new case infects less than one other person – so that total case numbers begin to decline.
The Maine CDC tracks R for several scenarios: total cases, cases outside nursing homes and other long-term care facilities, hospitalizations and deaths.
Early in the outbreak, Maine’s R appeared to be around 2. But as of late this week, its COVID-19 reproduction rate was at or approaching an R of 1 in each of those scenarios.
“We are quickly approaching one, and that’s a good sign,” Shah said during his daily briefing Thursday. “It doesn’t mean that we are out of the woods by any stretch because, as we’ve all talked about, that number can go back up as quickly as it can go back down.”
Hong Kong, Singapore and Germany, for instance, all saw their R’s dip below one before experiencing new infection spikes. And the Maine CDC warns that the confirmed cases – which stood at 1,123 on Friday – represent a fraction of total cases in the state because only a limited number of people are tested when they display symptoms.
“By definition, at 1, every case generates one more case,” Shah said. “It’s not an epidemic but we are still generating new cases every day.”
SIXTH-LOWEST INFECTION RATE
Many public health experts have said that before broadly lifting restrictions on social gatherings and business operations, a state should have a two-week decline in cases, deaths and hospitalizations; widespread access to testing for the public; and a robust track-and-trace system for identifying and monitoring people who have been exposed.
The Mills administration has said those measures are among the multiple metrics being tracked as decisions are made about the timing for lifting restrictions, although the latest executive order from Mills did not provide specific, numeric benchmarks.
Instead, the order said Maine must continue to see “a downward trajectory” of COVID-19 cases, hospitalizations and reported “influenza-like illnesses and COVID-19-like syndromic cases.” Additionally, Maine’s health care system must have the capacity to treat all patients and to “engage in a robust testing program.”
National data show that Maine is faring better than most states.
Maine’s confirmed COVID-19 infection rate of 83.9 for every 100,000 residents was the sixth-lowest among the 50 states and District of Columbia as of Friday, according to the most recent figures from the U.S. Centers for Disease Control and Prevention.
New Hampshire and Vermont were also in the bottom half of states, with infection rates of 158.2 and 138.3 for every 100,000 residents, respectively. The three southern New England states, on the other hand, ranked directly below New York and New Jersey as they each continued to experience surges. In Massachusetts, for instance, the rate was 901.2 per 100,000 residents – more than 10 times the rate in Maine.
Similarly, Maine’s death rate of four people per 100,000 residents is in the bottom third of the country, according to daily tracking and analysis by The New York Times. New Hampshire had a rate of five per 100,000 as of Friday, while both Connecticut and Massachusetts were reporting more than 50 deaths per 100,000. The hardest-hit state, New York, had a rate of 121 per 100,000 residents.
MAINE HAS ‘DONE A GOOD JOB’
Dr. Ali Mokdad, a senior faculty member at the University of Washington’s Institute for Health Metrics and Evaluation (IHME), said Maine appears to be in a better position than many states, in part because of its stay-at-home measures. But he cautioned that challenges lie ahead as the state seeks to reopen the economy.
“Maine has done a good job and can open much sooner than other states, but there will be the challenge of people coming from other states,” said Mokdad, who previously worked at the U.S. CDC. “Will you test at airports, for instance, or will you require visitors to quarantine? It’s a big challenge for states like Maine that have to weigh the economic impact (of losing a tourist season).”
The institute produces one of the most closely watched modeling systems to forecast deaths as well as hospital utilization and capacity in each state. IHME’s modeling predicts Maine will have deaths from COVID-19 flatline at 63 in mid-May.
In addition to its mortality predictions, which have been among the most accurate so far, IHME has developed a model to help predict when states might safely reopen. That model is based on when each state will see one new infection per million people, thereby allowing health officials to keep pace with testing and contact tracing.
Maine’s projected date is May 19, according to IHME, while five states – Alaska, Hawaii, Montana, West Virginia and Vermont – were expected to reach the benchmark by May 10. Twenty states were not projected to reach that threshold until June.
Mokdad stressed that states looking to ease restrictions should still limit mass gatherings and push for increased safety measures for businesses, something Mills has done.
RISING ‘GROWTH RATES’ IN RURAL AREAS
At the Dartmouth Atlas Project within New Hampshire’s Dartmouth College, researchers have been tracking COVID-19’s progression by analyzing cases in the regional markets where residents receive health care. The researchers then used The New York Times’ extensive disease-tracking system to show how infection rates are changing in each “hospital referral region.”
Maine was divided into two referral regions: Bangor and Portland. In cases per 100,000 residents, the Bangor region was 284th out of 306 regions and the Portland region ranked higher, at 187th.
In terms of growth rate of COVID-19 (as measured by the average daily growth over the past seven days), the Portland region’s 2 percent daily growth rate ranked it 232nd out of 306 regions nationwide. The Bangor hospital referral region, meanwhile, ranked 106th because it had a daily case growth rate of 4 percent over the previous week.
Stephanie Tomlin, director of the data analysis program at Dartmouth Atlas, said those growth rates show that COVID-19 infections are surging not only in places like the Boston area, but also in parts of more rural states. St. Cloud, Minnesota, for instance, had a daily growth rate of 34 percent while Sioux City, Iowa, had 25 percent daily growth during the previous week.
Tomlin noted that Maine, New Hampshire and Vermont have so far avoided becoming hotspots, although areas of southern New Hampshire along the Massachusetts border have had smaller surges in cases. But rising growth rates in other rural states should cause concern as more rural New England states consider relaxing restrictions.
“These rates matter, and they matter a lot in how they keep moving forward because it seems to me that social distancing is working,” Tomlin said. “I know our surge in New Hampshire is far less than expected, and that’s good. But as the weather changes and people start to come up here, we have to be concerned about growth rate.”
The same situation obviously applies to Maine, where second homes and out-of-state tourist traffic constitutes a major part of the state’s economy.
“I think we need to be very vigilant and follow the data, and the governors have to do that, too,” Tomlin said.
Staff Writer Eric Russell contributed to this report.
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