In March 2020, cities and states throughout the United States issued social distancing orders to mitigate the coronavirus disease (COVID-19) pandemic (1). In response to growing political and economic pressures, the White House and the Centers for Disease Control and Prevention issued guidelines for relaxing such measures on April 16, 2020 (2). However, the gating criteria in these guidelines do not include provisions, such as cocooning, to protect vulnerable populations. Residents of long-term care facilities (LTCFs) are particularly vulnerable because of congregate living, shortages in qualified workers, and the need for physical contact between caregivers and residents. In LTCFs, cocooning includes measures to increase staff; cohort residents; test for severe acute respiratory syndrome 2 (SARS-CoV-2), the causative agent of COVID-19; and assess availability of personal protective equipment and other infection control resources (3). Among other groups, cocooning involves incentivizing persons with high-risk underlying conditions to remain at home, helping persons experiencing homelessness to social distance, and broadly encouraging hand hygiene and wearing face masks for persons at high risk for severe illness or death and their caregivers (4).

By June 16, 2020, nursing home residents constituted 42.8% (50,919/119,055) of US COVID-19 deaths (5). In Austin, Texas, patients in LTCFs represented approximately half the COVID-19 deaths and >20% (81/398) of COVID-19 hospitalizations among persons with known residence (6).

To quantify the need for proactively protecting these vulnerable populations, we projected the effects of relaxation of shelter-in-place orders, with and without additional cocooning measures. We built a granular mathematical model of COVID-19 spread in US cities that incorporates age-specific and risk-stratified heterogeneity in the transmission and severity of COVID-19 (Appendix) (7). The model uses 70 stochastic differential equations to track the disease status in 10 subpopulations: low-risk and high-risk persons in each of 5 age groups, 0–4 years, 5–17 years, 18–49 years, 50–64 years, and >64 years of age. We focused on the Austin-Round Rock Metropolitan Statistical Area in Texas, the fastest-growing large city area in the United States, because we provide decision support for city leaders and have access to patient-level COVID-19 hospitalization and death data.

Persons initially are susceptible to SARS-CoV-2 and infection rates are dependent on age-specific contact rates and prevalence of infection. Upon infection, persons incubate SARS-CoV-2 asymptomatically before progressing to a symptomatic or asymptomatic infectious state. Depending on age and risk group, symptomatic COVID-19 case-patients might be hospitalized and die. To model cocooning of high-risk populations, we reduced the transmission rate to and from persons >64 years of age and in younger high-risk subgroups.

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Figure. Projected coronavirus disease (COVID-19) hospitalizations during February 16–December 31, 2020, in the Austin-Round Rock Metropolitan Statistical Area, Texas, USA, assuming strict social distancing measures are relaxed on May 1, 2020....

Social distancing began in Austin with school closures on March 14, 2020 and ramped up on March 24, 2020 with a Stay Home–Work Safe order (order 20200324-007; https://www.austintexas.gov). We assumed published values for most model parameters (Table; Appendix) and calibrated the transmission rate before and after the stay-home order based on hospitalization counts (Figure). During March 24–April 23, data suggest that SARS-CoV-2 transmission dropped by 70% (95% CI 45%–100%). If social distancing measures were completely relaxed on May 1, 2020, we estimated that COVID-19 hospitalizations would surpass Austin’s surge capacity of 3,440 beds in 27 (95% CI 16–43) days, on May 28 (Figure). Assuming instead that individual behavior and public health efforts continued to reduce transmission by 75% relative to the stay-home order, hospital surge capacity would be reached after 84 (95% CI 41–137) days, on July 24. When we superimposed cocooning to reduce transmission risk by 125% relative to the stay-home period for 547,474 persons at high risk among the total population of 2,168,316 (Appendix), Austin could avoid hospital surge and reduce cumulative COVID-19 hospitalizations by 62% and deaths by 70% (Appendix Table 1). Postponing relaxation of shelter-in-place measures would not prevent a second pandemic wave but could buy more time to protect vulnerable populations (Appendix Figure 1).

Cities likely will experience additional waves of COVID-19 when social distancing orders are relaxed. Our model indicates that Austin must aggressively reduce SARS-CoV-2 spread to avoid overwhelming hospital capacity by the end of 2020. Without cocooning, measures that reduce transmission with >90% the efficacy of the stay-home order are needed; with cocooning, social distancing measures for persons at lower risk can be more relaxed (Appendix Figure 1). Cocooning of older adults and persons with known high-risk conditions (8) can protect thousands in Austin and millions worldwide. The high-risk population in Austin, as in many cities, is diverse; 66% are >65 years of age, »5,000 are residents in LTCs, and almost 3,000 are persons experiencing homelessness (9). Cocooning should be resourced proactively and tailored to meet the distinct needs of high-risk subgroups, including work-at-home and paid leave programs that enable high-risk workers to self-isolate (10). Concerted efforts also are needed to shelter residents of LTCs (3) and persons experiencing homelessness, where risks are compounded by group living conditions that amplify COVID-19 transmission. Thus, cocooning should be added to the national gating criteria prior to relaxation of social distancing.

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