Social distancing to slow the U.S. COVID-19 epidemic: an interrupted time-series analysis

Siedner, Mark J; Harling, Guy; Reynolds, Zahra; Gilbert, Rebecca F; Venkataramani, Atheendar; Tsai, Alexander C

Background: Social distancing measures to address the U.S. COVID-19 epidemic may have significant health, social, and economic impacts. Objective: To estimate the mean change in state-level COVID-19 epidemic growth before versus after the implementation of statewide social distancing measures. Design: Interrupted time-series analysis. Setting: United States. Measurements: Our primary exposure was time in relation to implementation of the first statewide social distancing measure. The pre-implementation period began 14 days prior to implementation and included up to 3 days after implementation to account for incubation. Post-implementation began 4 days after, up to and including March 30. Our primary outcome was the COVID-19 growth rate, calculated as the log of daily COVID-19 cases minus the log of daily COVID-19 cases on the prior day. Results: All states applied some form of statewide social distancing between March 10-27. The mean daily COVID-19 growth rate decreased beginning four days after implementation of the first statewide social distancing measures, by an additional 0.8% per day; 95% CI, -1.4% to -0.2%; P=0.002). This reduction corresponds to an increase in doubling time of the epidemic from 3.3 days (before) to 5.0 days (at 14 days after implementation). Limitations: Potential bias due to the aggregate nature of the ecological data, potential confounding by contemporaneous changes (e.g., increases in testing), and potential underestimation of social distancing due to spillovers across neighboring states. Conclusion: Statewide social distancing measures were associated with a decrease in U.S. COVID-19 epidemic growth. Based on the size of the epidemic at the time of implementation in each state, social distancing measures were associated with a decrease of 3,090 cases at 7 days, and 68,255 cases at 14 days, after implementation.