public health

How Will New York City Respond to the Coronavirus?

A New York City Police officer stands at the entrance to Bellevue Hospital during the 2014 Ebola scare. Photo: Bryan Thomas/Getty Images

Confirmed cases of the novel coronavirus have been identified in more than 50 countries, and officials around the world are instituting measures to stem the spread of the virus. Switzerland has banned gatherings of 1,000 or more people; Saudi Arabia has stopped pilgrimages to holy sites; and Japan closed its schools for at least a month. On Sunday night, New York officials reported the state’s first confirmed case of the coronavirus — a Manhattan woman in her 30s who contracted COVID-19 while traveling abroad in Iran. On Friday, city officials announced that the city’s health-care system was digging in for the virus’ inevitable arrival. “We all ask ourselves the question after seeing the CDC guidance,” Mayor Bill de Blasio said at a press conference on Wednesday, “what would we be able to do if this became a much deeper crisis?” So … what will New York City look like if there is a coronavirus outbreak here?

Though there are systems in place to deal with a pandemic, the novel coronavirus seems likely to test the city’s public health authorities and affect day-to-day life in New York far more than Ebola, SARS, MERS, or H1N1 did — perhaps in predictable ways. But the city’s responses to past outbreaks, interviews with experts, and official guidelines on handling influenza pandemics, offer at least a glimpse at what the policies health officials might pursue.

While preparing for a pandemic, officials will look to the CDC and the World Health Organization, which uses a six-phase alert system. Phase one is an average day, when the only threat of a pandemic is the one lurking in some mammalian host; phase two is when an animal influenza has been passed to humans; phases three and four indicate that a novel virus is being passed between people in clusters; phase five is when the virus is being transmitted between people in more than one country; and phase six is a full-on pandemic — widespread human infection. The WHO is not in phase six, but many scientists have said the coronavirus has already reached pandemic level.

During periods when there is no immediate potential of pandemic on the horizon, the city prepares. Doctors and nurses run drills; working groups offer policy suggestions; information is distributed to the public. Phases four and five are the “pandemic alert period.” Officials watch ports of entry closely. Passengers from affected countries are screened and given informational materials. The decision to impose a quarantine on a traveler or groups of travelers would be up to federal or state officials, as was the case in the 2014 Ebola scare, when Governor Cuomo signed an order to enforce mandatory quarantines for people traveling from West Africa who’d had “direct contact” with the virus.

A member of the Community Outreach Team hands out information about Ebola to residents outside an apartment building at 172nd Street and Stratford Ave in 2014. Photo: Don Emmert/AFP via Getty Images

But it’s during phase six — an actual pandemic — when real disruption may be necessary to curb the spread of the virus. Once there is evidence of transmission between people in New York, monitoring the airports and other ports of entry is less important. “The proverbial cat is out of the bag at that juncture and you’re better off taking your limited resources and using them in other places than taking temperatures of people at the airports,” says Dr. Michael Augenbraun, director of infectious diseases at SUNY Downstate Medical Center and Kings County Hospital.

Once the virus is spreading in the city, officials will promote or enforce “social-distancing” guidelines meant to limit contact between people. The science behind social distancing is unclear and varies based on the nature of the virus. According to a 2007 study of the 1918 flu pandemic, social distancing measures like school closure, cancelation of public gatherings, and isolation and quarantine effectively stemmed the spread of a flu virus. The CDC guidelines for triggering social-distancing measures are based on how contagious the virus is and the number of infections. The CDC grades the severity of pandemics on a scale from one (seasonal influenza) to five (something like the 1918 pandemic, when the mortality rate was above 2 percent). Generally, only voluntary home isolation and quarantine are recommended for pandemics that rise to category three. More aggressive measures like school closures aren’t recommended until a pandemic reaches category four or category five.

When deciding whether to close a school, the New York City Department of Health and Mental Hygiene — or DOHMH — and school officials will consider a host of factors, including mortality and hospitalization rates among children and the likelihood that kids will spread the virus outside of school. The DOHMH recently studied the effects of school breaks on emergency room visits for school-aged children with influenza and found a decline just two to three days after breaks began. The CDC guidelines recommend closures up to four weeks for a less severe pandemic and up to 12 weeks for severe pandemics. During the 2009 H1N1 pandemic, the DOHM closed at least six schools in response to the virus.

With more than 1 million students home from school, many parents will be forced to call out or work from home, though large employers may already be requiring their employees to do so.  Once workplace measures are instituted, so too are measures limiting large social gatherings. Broadway shows could be canceled, concerts postponed, and the Knicks and Nets may play home games on the road, or to empty stadiums, as soccer teams in Iran and Italy did last week. Like school closings, other community-level social-distancing measures could last anywhere from four to 12 weeks.

One influenza study found that only four percent of flu infections happen on the subway. Photo: Drew Angerer/Getty Images

Even in a category five (the CDC’s most severe pandemic), essential services will continue to operate. The power grid would remain on and, though rush-hour traffic will be thin, it is likely that the subway would keep running on a modified schedule. Earlier this week, the MTA announced that it was already discussing contingency plans that could limit or otherwise disrupt public transit. (Though much of the science is out on the novel coronavirus, a 2011 study found that only four percent of influenza infections occurred on the subway.) Maintaining the transit system is essential to assure everyone has access to care. In 2010, the DOHMH identified neighborhoods most vulnerable to a pandemic based on, among other factors, their proximity to care. Coney Island, Southwest Bronx, Morningside Heights, Bedford-Stuyvesant, East New York, and Crown Heights were at the highest risk.

Nowhere would the ripple effects of social distancing have a greater impact than in hospitals. Health-care workers — contending with limited public transit, kids home from school, and their own health concerns — would be working overtime to keep up with new admissions and scores of worried well. On Wednesday, Mayor de Blasio said that the city had set aside an extra 1,200 beds at hospitals around the city. New York State estimates that in the event of a severe epidemic, hospitals across the state would see 1 million admissions — as many as 26,300 per day. Administrators might cancel elective surgeries to channel resources toward more urgent needs. Critical supplies would be increasingly hard to come by. In 2015, New York State issued guidelines on how to ethically allocate limited resources during a severe influenza pandemic and estimated 18,619 ventilators would be needed — 15,783 more than hospitals have in their reserves. Basic medical supplies like N95 masks and face visors would be in even higher demand. “The amount of equipment we went through with Ebola was staggering,” says Dr. Kate Uraneck, who was a senior physician in emergency preparedness in the DOHMH in 2014. “Even with one patient, the cost and the amount of protective equipment we went through every day was amazing.” New York State has been stockpiling supplies in three temperature-controlled hidden warehouses, according to the New York Times.

Tourists wearing masks walk through Union Square in New York City on February 28. Photo: Timothy A. Clary/AFP via Getty Images

The vast majority of deaths would occur in hospitals (70 percent, by one estimate), but in a category-five epidemic, dealing with all of the bodies will be its own grim challenge. The Office of Chief Medical Examiner has guidelines for a severe pandemic with a 2.1 percent mortality rate that would produce nearly 51,000 bodies across the city. The city has plans in place for teams of body collectors — supplemented by death professionals like morticians, forensic photographers, and medical students — to recover anywhere from 50 to more than 5,000 cadavers a day. During a surge, mobile refrigerated storage units capable of housing up to 44 bodies will be placed at locations around the city. To dispose of the bodies, the city’s cremation capacity could be ramped up. As a last resort, the city has plans to send corpses to Hart Island in the Long Island Sound where, in the late 19th century, yellow-fever patients were quarantined. Prisoners from Rikers Island would be ferried over to do the digging.

Few cities have the health-care infrastructure that New York already has in place to deal with a pandemic. “New York City has been handling infectious-disease outbreaks for a long, long time. It has a storied history going back to before Typhoid Mary,” says Dr. Amesh Adalja, an infectious-disease expert at Johns Hopkins Center for Health Security. “They’ve dealt with Ebola, West Nile, anthrax, and many issues that no other health department has had to deal with.” Should a vaccine be developed and brought to market rapidly, New York City can administer it quickly. During the 2009 H1N1 pandemic, New York vaccinated 195,000 kids at 1,200 schools, and an additional 50,000 people at other locations across the city. In 1947, the city vaccinated more than 6 million people during a smallpox outbreak. But, at this point, even the most hopeful estimates suggest a vaccination is many months away.

This post has been updated to note the first confirmed coronavirus case in New York.