Effectiveness of Social Distancing Interventions to

Curve the COVID-19 Pandemic and Impact of

Relaxation on Healthcare Utilization in Ohio
A Public Health Policy Brief

April 29, 2020

Drs. Diego F. Cuadros, Neil MacKinnon, Yanyu Xiao, Andres Hernandez, Esteban Correa, Hana Kim,
Zhiyuan Yao, Rajinder Mavi and Ana Hincapie: The Geospatial Health Advising Group (GHAG)
For more information, please contact Dr. Diego Cuadros (cuadrodo@ucmail.uc.edu)

Introduction of COVID-19
The novel coronavirus SARS-CoV-2 virus emerged in Wuhan, China, in late November or early
December 2019. As of April 27, 2020, it was responsible for 3,029,452 confirmed cases and 210,374
deaths of the disease COVID-19 (WHO). After initial emergence in China, travel associated cases started
to appear in other parts of the world with strong travel connections to Wuhan. The first confirmed case
in the US was a travel-associated case in Snohomish County, WA, screened on January 19, 2020. As of
April 28th, Ohio reported 16,769 confirmed cases, 3,340 hospital admissions, 1,004 intensive care unit
(ICU) admissions, and 799 confirmed deaths associated with COVID-19.

Addressing COVID-19 Through Social Distancing

The benefits from a delayed and flattened outbreak are to reduce overcrowding of the health system.
More importantly, keeping the health system operating below maximum capacity has direct mortality
benefits for both acutely ill COVID-19 patients and for others who will continue to need non-COVID
related healthcare. Social distancing measures are critical to slow the progression of the COVID-19
epidemic. Still, there is a great deal of uncertainty about the scale of the epidemic and the effect of
current social distancing policies. Ohio currently has 3,743 ICU beds, of which 1,719 are currently
available. A total of 58 counties have less than 10 ICU beds available and only 10 counties have more
than 25 ICU beds available.

We used data from March 1 to March 23 (before the stay home order was implemented) to model the
COVID-19 cases and COVID-related hospitalizations and deaths in Ohio. Projections with this baseline
scenario indicated that the epidemic would have continued growing exponentially with roughly 13,000
cumulative COVID-related hospitalizations and 1,080 deaths by April 15, compared to 2,472
hospitalizations and 393 deaths reported by that date.

In this policy brief, we describe projections for the burden of COVID-19-related hospitalizations, ICU
admissions, and deaths through June 30 based on modeling results informed by data collected by the
Ohio Department of Health through to April 15. The aims of our analysis are: 1) estimate the impact of
the public health interventions such as social distancing and stay home order in the spread of the
disease implemented in mid-March, and 2) evaluate the impact of the relaxation of the current
interventions on the health care capacity in Ohio.

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Social Distancing Options and Impact in Ohio Moving Forward
We have evaluated the impact of the relaxation of the current social distancing intervention in the
dynamics of the COVID-19 epidemic in Ohio. Assuming that the current interventions such as social
distancing and stay home orders are relaxed on May 1, we generated four scenarios with different
intensities in the relaxation of the intervention: no change (0%), minimal relaxation (20%), moderate
relaxation (50%), and significant relaxation (70%). The scenarios describe the generalized impacts of
social distancing policies but do not currently speak to specific policy recommendations on issues like
school closures, event cancellation, and work policies.

If the current intervention is not changed, the model projects 4,816 hospitalizations associated with
COVID-19 by June 1, compared to 7,682 hospitalizations if the current intervention is relaxed
moderately (by 50%), and 10,846 if the intervention is relaxed significantly (by 70%). Regarding COVID-
19 -related mortality, if the intervention is not changed, the model projects 1,073 cumulative deaths
associated with COVID-19 complications by June 1, compared to 1,367 deaths if the intervention is
relaxed moderately, and 1,629 deaths if the intervention is relaxed significantly (Figure 1).

Figure 1. Projected number of cumulative number of COVID-related hospitalizations (left) and deaths (right) assuming no
change in the current intensity of the social distancing intervention (orange line), 20% reduction (grey line), 50% reduction
(yellow line) and 70% reduction of the intervention (blue line)

If the current intervention is relaxed minimally, the number of ICU beds occupied by COVID-19 patients
would remain stable over time, and 200 ICU beds would be occupied by COVID-19 patients by June 30.
In contrast, if the current intervention is relaxed moderately, the number of ICU beds occupied by
COVID-19 patients would start increasing 15 days after the intervention is relaxed, and 67 counties
would reach full ICU bed capacity. If the current intervention is relaxed significantly, maximum ICU
beds capacity would be reached by June 13, and more than 7,000 ICU beds would be needed by June
30 (Figure 2). The model estimated that if the current intervention is not changed, 55 counties would
have less than 10 deaths associated with COVID-19 by June 30, and only Montgomery, Hamilton,
Franklin, Cuyahoga and Summit would have more than 50 deaths by June 30. If the current
intervention is relaxed moderately, only 25 counties would have less than 10 deaths, and 27 counties
would have more than 50 deaths by June 30. If the current intervention is relaxed significantly, only
four counties would have less than 10 deaths, 50 counties would have more than 50 deaths, and 20
counties would have more than 200 deaths by June 30 (Figure 2).

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Figure 2. Projection of the spatiotemporal dynamics of the ICU beds available and cumulative number of COVID-related
deaths under different scenarios of relaxation of the current social distancing interventions in Ohio

Recommendations
Our analysis suggests that minimal relaxation of the current social distancing interventions (about 20%
reduction) would maintain the critical care demand for COVID-19 patients at a stable level, whereas
moderate to significant relaxation of the interventions (between 50% to 70%) would require the
implementation of an intermittent social distancing strategy, in which strict social distancing
interventions need to be reintroduced about six weeks after the social distancing measures are lifted.
However, this threshold needs to be estimated in more details, and we are currently working on
generating more accurate estimates needed for the implementation on the intermittent social
distancing strategy in Ohio.

It is also important to note that there is substantial geographical variation not only in the spread of the
virus but also in the healthcare capacity within the state. Although counties such as Franklin, Cuyahoga
and Hamilton have the highest burden of COVID-19 cases, they are also the counties with the highest
healthcare capacity. Thus, the critical care capacity threshold for these counties is reached more slowly
compared to other counties with lower burden of cases but low critical care capacity such as Trumbull,
Delaware and Claremont, which would have a deficit of more than five ICU beds by June 15, and
counties such as Lake, Butler, Trumbull, Delaware, Mahoning and Clermont, which would have a deficit
of more than 20 ICU beds by June 30 if the current social distancing interventions are relaxed
moderately. Therefore, we recommend to strengthen the healthcare capacity of these counties in
order to have an effective intermittent social distancing approach in the entire state.

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Appendix: Methods, Online Resources, and References

We constructed a deterministic compartmental mathematical model to describe the dynamics of confirmed

COVID-19 cases, COVID-19-related hospitalizations and ICU admissions, and COVID-19-related deaths in Ohio.
The model was designed to be spatially-explicit by incorporating spatial risk information by county. The model
consists of a set of coupled nonlinear differential equations that stratify the population into compartments
according to spatial risk group, infection status, hospitalization, and disease stage. Analyses were performed in
MATLAB R2017a

The model stratified the population into four different spatial groups depending of spatial risk characteristics of
the county. The spatial risk groups were defined as following, Group 1: counties with airports; Group 2: counties
surrounding the counties with airports; Group 3: counties with main highways crossing the county; and Group 4:
counties not surrounding counties with airports or being crossed by main highways. Each group has its own
dynamic of the disease and the directional connections between groups are assumed to be by flow of infections
between the different groups at specific rates. The dynamic of the disease transmission and infection
complications in each group was modeled using seven epidemiological compartments for the susceptible,
infected, recovered, hospitalized, ICU admitted, recovered after hospitalization, and death population.
Susceptible individuals in each spatial group are at risk of being exposed to the infection at varying hazard rates,
which are group- and time dependent, to capture the variability in the risk of exposure and the impact of public
health interventions.

The model was fitted to the following sources of data: 1) time series the cumulative number of diagnosed
COVID-19 cases, 2) time series of the cumulative number of COVID-19-related hospitalizations, 3) time series of
the cumulative number of ICU admissions, and 4) time series of the cumulative number of COVID-19 deaths in
Ohio from March 01 to April 15. Data come from the Ohio Health Department
(https://coronavirus.ohio.gov/wps/portal/gov/covid-19/dashboards/overview). Model fitting was used to
estimate the hazard rate in each spatial-risk group, rate of infection flow between spatial-risk groups,
hospitalization rate, duration of hospitalization, ICU admission rate, duration in ICU, recovery from ICU and
death rate. The model was also used to estimate the impact of public health interventions such as social
distancing and stay home order. A nonlinear least-square data fitting method, based on the Nelder-Mead
simplex algorithm, was used to minimize the sum of squares between data points and model predictions.

Access to Online Mapping Resources

Our team is using the Webmap app to host all the maps we are generating with our analysis, which can be
accessed in this link.

References

Chalfin, D.B., Trzeciak, S., Likourezos, A., Baumann, B.M., & Dellinger, R.P. (2007). Impact of delayed transfer of
critically ill patients from the emergency department to the intensive care unit. Critical care medicine,
35, 1477-1483.
Hatchett, R.J., Mecher, C.E., & Lipsitch, M. (2007). Public health interventions and epidemic intensity during the
1918 influenza pandemic. Proceedings of the National Academy of Sciences, 104, 7582-7587.
Rubinson, L., Mutter, R., Viboud, C., Hupert, N., Uyeki, T., Creanga, A., et al. (2013). Impact of the fall 2009
influenza A (H1N1) pdm09 pandemic on US hospitals. Medical care, 51, 259.