Why the Bay Area is issuing more severe coronavirus warnings than Southern California

SAN FRANCISCO —  Up to now, some Bay Area public health agencies have been more aggressive than those in Los Angeles and some other counties in issuing coronavirus-related restrictions.

But that could be about to change.

With the first case of the coronavirus believed to be transmitted within the community now reported in Los Angeles County, the experiences in the San Francisco Bay Area may offer a glimpse for what Southern California is in for.

The Los Angeles County director of public health, Barbara Ferrer, on Monday called for “social distancing,” a term officials use to describe keeping people away from crowded areas in hopes of dramatically reducing the spread of an infectious disease.

Her call came after one of two newly confirmed cases of the coronavirus in L.A. County had an unidentified source of exposure. That indicates the virus is being passed through people in the community, even those without history of travel or close personal contact with people known to be infected.

Several counties in the San Francisco Bay Area have already implemented extraordinary measures to implement social distancing after it became clear the virus was also spreading in the community, and institutions have responded here and elsewhere throughout California. UC Berkeley, San Francisco State, San Jose State, Santa Clara University, UC San Diego, and Stanford University are moving classes online; a Stanford faculty member has tested positive for the coronavirus.

The danger became especially clear on Monday, when Silicon Valley reported its first death related to the new coronavirus Monday: a woman in her 60s who had been hospitalized for several weeks, and had been the first person in Santa Clara County to be known to be infected with the virus without having traveled internationally or known contact with an infected person. It was California’s second death related to the new coronavirus.

With the number of cases growing rapidly in Silicon Valley, rising to 43 Monday from just 11 on Thursday, the health officer of the county with the most number of cases statewide, Santa Clara County, issued a rare legal order enforceable by the sheriff banning mass gatherings of 1,000 or more people. The San Jose Sharks, which had late last week continued to play a game despite a county recommendation to halt mass gatherings, said it would comply with the new order.

In San Francisco, the St. Patrick’s Day Parade and performances of the San Francisco Symphony have been canceled.

But even smaller gatherings should be canceled, officials said, in the interest of halting the spread of disease.

“All non-essential gatherings should be canceled, postponed, or done remotely,” Dr. Scott Morrow, health officer for San Mateo County, said in a statement Thursday. “Unfortunately, at this time, I have no standard definition of ‘non-essential’ or ‘gathering’ to guide your decisions. Use your best judgment.”

Even a prom was canceled when the largest school district in Northern California, the Elk Grove Unified School District in Sacramento County, said Saturday it was moving up its spring break and closing schools and canceling all student activities this week after some parents and family members, but no students, tested positive for the virus.

The San Francisco Unified School District canceled or postponed nonessential events for the next two weeks, including a mariachi festival and a solo and ensemble music festival. The health officer banned visitors from entering Laguna Honda Hospital and Rehabilitation Center, a violation of which is a misdemeanor.

“We are clearly facing a historic public health challenge,” Dr. Sara Cody, the public health officer for Santa Clara County, said Monday night at a press conference.

Some have chosen not to follow the recommendations of health officials; the Golden State Warriors played at the Chase Center in San Francisco on Saturday, a day after the city’s health officer advised canceling mass gatherings.

But the public seemed to be hunkering down. BART’s ridership was down last week by 8% compared with the week before, a spokesman said, and the BART commute Monday morning seemed particularly light, coming as the region closely monitored the arrival of more than 3,500 stranded people on the Grand Princess cruise ship into the Port of Oakland. At least 21 people — 19 of 1,100 crew members and two passengers — on the ship have confirmed cases of COVID-19, the disease caused by the coronavirus that originated late last year in Wuhan, China.

Cities announced measures to avoid mass gatherings: Senior classes across San Francisco were canceled, from Argentine tango in Noe Valley to mah jong in Nob Hill. San Jose’s senior meals program is transitioning to a boxed to-go, pickup format.

Libraries in San Francisco, Redwood City and Santa Clara were canceling all major events for at least a week. The city council chambers in Santa Clara were reconfigured to allow for more space among seats for social distancing.

Transit agencies did their best to reassure commuters. BART said it was wiping down hand-contact surfaces with “hospital-grade disinfectant more frequently each day.”

People seemed to be staying at home. On Sunday evening in San Jose’s Little Saigon, it seemed to be much easier to find a parking space for popular restaurants. Along the streets in downtown Millbrae, near the San Francisco International Airport, the sidewalks seemed to have emptied out.

Health officials said they understood these recommendations and actions were disruptive. But to work, the measures need to seem like an overreaction.

“If we wait to take stronger action until we have multiple confirmed cases and deaths, the window of opportunity that we have now will have closed,” Dr. Grant Colfax, San Francisco director of health, said Friday night. “We acknowledge that there will be unintentional hardships and sacrifices for our residents and businesses. But it is the best thing for public health and to protect all of us from a worsening outbreak that is quickly spreading across the country and our region.

“If the plan works in San Francisco, it may even seem like an overreaction. Because the virus spread will be reduced and fewer people will get sick,” Colfax said.

The goal of telling people to avoid crowds is to prevent many illnesses hitting the region all at once, health experts said.

“Our goal is to not have them all at once,” said Dr. Shanthi Kappagoda, clinical associate professor of infectious diseases at Stanford University, “so that our local hospitals and clinics are not overwhelmed.”

While about 80% of those who do get infected have mild illness, certain populations, like the elderly and those with underlying medical conditions, are at far greater risk of severe illness and death.

Measures such as closing schools, churches and theaters were associated with lower peak death rates during the 1918 flu pandemic, a study in the Proceedings of the National Academy of Sciences in 2007 found.

In particular, the difference in how Philadelphia and St. Louis handled the flu was striking. Philadelphia downplayed the significance of the flu and allowed a citywide parade to continue 11 days into the outbreak, and by the time officials ordered school closures and other bans on public gatherings five days after the parade, it was too late — “disease spread had already begun to overwhelm local medical and public health resources,” the study said.

St. Louis, meanwhile, enacted social distancing measures two days after the flu arrived. The result was that Philadelphia’s peak death rate was dramatically worse than St. Louis’.

U.S. officials warn that peak demand for intensive care unit beds and the number of ventilators needed to help severely ill people breathe would be in extremely short supply in a pandemic.

That’s why slowing down the spread of the disease is so important, to reduce demand on hospitals, according to the U.S. Centers for Disease Control and Prevention’s pre-pandemic strategy.

Telling the public to avoid crowds can reduce the number of daily illnesses in an outbreak or pandemic, reducing the burden on hospitals and clinics.

(U.S. Centers for Disease Control and Prevention )

“If I were going to have a bunch of 90-year-olds at a birthday party, I probably wouldn’t have that many there — and I certainly wouldn’t have a lot of kids running around infecting them,” said Dr. George Rutherford, an epidemiologist and infectious disease expert at UC San Francisco.

Fears of the virus are well-placed when it comes to protecting the elderly and those with underlying medical conditions and focusing efforts on “keeping this virus away from nursing homes, long-term care facilities and elderly people whose lungs can’t recover from this,” said Dr. Jeremy Faust, emergency physician at Brigham and Women’s Hospital and an instructor at Harvard Medical School.

Those at higher risk include those over the age of 70 and with underlying medical conditions such as diabetes, obesity, asthma, disease of the heart, lung or kidney and those with weakened immune systems. If infection control fails, early diagnosis is important, to give more time to treat the patient, offering help such as providing oxygen or putting the patient on a ventilator to help them breathe if their lungs begin to fail.

Taking common-sense measures to protect the elderly should be a priority, Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, said in a video interview with the editor of the Journal of the American Medical Assn. posted Friday.

Among the top priorities, he said, was getting nursing homes up to speed with regard to infection control.

“You saw what happened in the Seattle area — that’s not the last time that’s going to happen,” Fauci said.

Among the recommendations and orders issued by officials in San Francisco, San Mateo and Santa Clara counties:

They include:

• San Francisco has canceled all nonessential mass gatherings of 50 or more people where people aren’t separated by at least four feet from each other (about the length of an average arm) at City Hall, Moscone Center, Bill Graham Civic Auditorium, New Conservatory Theatre, War Memorial & Performing Arts Center, Palace of Fine Arts Theatre, San Francisco Public Library, Pier 27 and Pier 35.
• Recommendations to cancel concerts, sports events, conventions and large community gatherings.
• Encourage people older than 50 and those with underlying health conditions from going to mass gatherings. Underlying conditions include heart disease, diabetes, cancer, lung disease, obesity and weakened immune systems.
• Tell businesses to suspend nonessential employee travel.
• Minimize the number of employees working within arm’s length of one another.
• Minimize or cancel large in-person meetings or conferences.
• Tell employees to stay home when they’re sick.
• Urge maximum flexibility in sick leave benefits.
• Don’t require a doctor’s note for sick workers.
• Consider telecommuting.
• Consider staggering start and ends times for employee shifts to reduce large numbers of people coming together at the same time.
• For events that still go on, ensure there’s handwashing, hand sanitizers and tissues available, and high-touch surface areas and hand rails are frequently cleaned.
• Telling the public to not go out when sick.
• Transit vehicles: increase cleaning of vehicles and high-touch surface areas.
• Nursing homes and long-term care facilities: Screen all staff and visitors for illness, and turn sick people away.
• Hospitals: If it’s not needed, the public should avoid hospitals, nursing homes and long-term care facilities. Even healthy people should stay away if it’s not essential to go there.
• If you are ill: Call your healthcare provider first; you might be able to be served by phone. Visit emergency rooms only when essential.
• Wash hands with soap and water for at least 20 seconds.
• Stop shaking hands.
• Cover coughs or sneeze with a tissue, if available, or into the elbow.
• Use a paper towel or tissue to touch commonly touched surfaces like elevator buttons and door handles.
• Under all circumstances, stop touching your face, eyes, nose or mouth with your unwashed hands.

Lin reported from San Francisco; Shalby from Los Angeles. Times staff writers Soumya Karlamangla and Stephanie Chavez contributed to this report from Los Angeles.