Social distancing to slow the U.S. COVID-19 epidemic: longitudinal pretest-posttest comparison group study

Background Social distancing measures to address the US coronavirus disease 2019 (COVID-19) epidemic may have notable health and social impacts. Methods and findings We conducted a longitudinal pretest-posttest comparison group study to estimate the change in COVID-19 case growth before versus after implementation of statewide social distancing measures in the US. The primary exposure was time before (14 days prior to, and through 3 days after) versus after (beginning 4 days after, to up to 21 days after) implementation of the first statewide social distancing measures. Statewide restrictions on internal movement were examined as a secondary exposure. The primary outcome was the COVID-19 case growth rate. The secondary outcome was the COVID-19-attributed mortality growth rate. All states initiated social distancing measures between March 10 and March 25, 2020. The mean daily COVID-19 case growth rate decreased beginning 4 days after implementation of the first statewide social distancing measures, by 0.9% per day (95% CI -1.4% to -0.4%;P< 0.001). We did not observe a statistically significant difference in the mean daily case growth rate before versus after implementation of statewide restrictions on internal movement (0.1% per day; 95% CI -0.04% to 0.3%;P =0.14), but there is substantial difficulty in disentangling the unique associations with statewide restrictions on internal movement from the unique associations with the first social distancing measures. Beginning 7 days after social distancing, the COVID-19-attributed mortality growth rate decreased by 2.0% per day (95% CI -3.0% to -0.9%;P< 0.001). Our analysis is susceptible to potential bias resulting from 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 spillover effects from neighboring states. Conclusions Statewide social distancing measures were associated with a decrease in the COVID-19 case growth rate that was statistically significant. Statewide social distancing measures were also associated with a decrease in the COVID-19-attributed mortality growth rate beginning 7 days after implementation, although this decrease was no longer statistically significant by 10 days. Author summaryWhy was this study done? There are few empirical data about the population health benefits of imposing statewide social distancing measures to reduce transmission of severe acute respiratory syndrome coronavirus 2, which causes coronavirus disease 2019 (COVID-19). What did the researchers do and find? We compared data from each state before versus after implementation of statewide social distancing measures to estimate changes in the mean daily COVID-19 case growth rate. The case growth rate declined by approximately 1% per day beginning 4 days (approximately 1 incubation period) after statewide social distancing measures were implemented. Our model implies that social distancing reduced the total number of COVID-19 cases by approximately 1,600 reported cases at 7 days after implementation, by approximately 55,000 reported cases at 14 days after implementation, and by approximately 600,000 reported cases at 21 days after implementation. What do these findings mean? Statewide social distancing measures were associated with a reduction in the growth rate of COVID-19 cases in the US. Our analysis is susceptible to potential bias resulting from the aggregate nature of the data, potential confounding by other changes that occurred during the study period (e.g., increases in testing), and potential underestimation of social distancing due to spillover effects from neighboring states.