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Comparison of Estimated Rates of Coronavirus Disease 2019 (COVID-19) in Border Counties in Iowa Without a Stay-at-Home Order and Border Counties in Illinois With a Stay-at-Home Order

Educational Objective
To understand how stay-at-home orders and a lack of stay-at-home orders can affect COVID-19 rate of infection between neighboring counties
1 Credit CME
Key Points

Question  Was the stay-at-home order in Illinois associated with different rates of coronavirus disease 2019 (COVID-19) compared with Iowa, which did not issue a stay-at-home order?

Findings  This cross-sectional study of border counties in Iowa and Illinois used difference-in-differences design and found an increase in estimated rates of COVID-19 cases per 10 000 residents in the border counties in Iowa compared with the border counties in Illinois after a stay-at-home order was implemented in Illinois but not in Iowa.

Meaning  The results of this study suggest that issuing a stay-at-home order in Iowa may have helped limit the spread of COVID-19 cases in that state.

Abstract

Importance  Iowa is 1 of 5 states in the US that have not issued a stay-at-home order during the coronavirus disease 2019 (COVID-19) pandemic. There is no empirical evidence on whether issuing a stay-at-home order in Iowa could have been associated with a reduced rate of COVID-19 infections in the state.

Objective  To compare COVID-19 cases in border counties in Iowa, which did not issue a stay-at-home order, with cases in border counties in Illinois, which did issue a stay-at-home order.

Design, Setting, and Participants  This cross-sectional study with a difference-in-differences design compared daily changes in COVID-19 cases per 10 000 residents in 8 Iowa counties bordering Illinois with those in the 7 Illinois counties bordering Iowa before and after Illinois issued a stay-at-home order on March 21, 2020. Additional sensitivity analyses were conducted to account for differences in timing of closing schools and nonessential businesses between the 2 states and differential trends in COVID-19 cases by county population density and poverty rates.

Exposures  Issuing a stay-at-home order.

Main Outcomes and Measures  Comparison of cumulative cases of COVID-19 per 10 000 residents in border counties in Iowa and Illinois.

Results  The total populations were 462 445 in the Iowa border counties and 272 385 in the Illinois border counties. Population density was higher in the Iowa counties (114.2 people per square mile) than in the Illinois counties (78.2 people per square mile). Trends of cumulative COVID-19 cases per 10 000 residents for the Iowa and Illinois border counties were comparable before the Illinois stay-at-home order, which went into effect at 5:00 pm on March 21 (March 15 to March 21: 0.024 per 10 000 residents vs 0.026 per 10 000 residents). After that, cases increased more quickly in Iowa and more slowly in Illinois. Within 10, 20, and 30 days after the enactment of the stay-at-home order in Illinois, the difference in cases was −0.51 per 10 000 residents (SE, 0.09; 95% CI, −0.69 to −0.32; P < .001), −1.15 per 10 000 residents (SE, 0.49; 95% CI, −2.12 to −0.18; P = .02), and −4.71 per 10 000 residents (SE, 1.99; 95% CI, −8.64 to −0.78; P = .02), respectively. The estimates indicate excess cases in the border Iowa counties by as many as 217 cases after 1 month without a stay-at-home order. This estimate of excess cases represents 30.4% of the 716 total cases in those Iowa counties by that date. Sensitivity analyses addressing differences in timing of closing schools and nonessential businesses and differences in county population density and poverty rates between the 2 states supported these findings.

Conclusions and Relevance  This cross-sectional study with a difference-in-differences design found an increase in estimated rates of COVID-19 cases per 10 000 residents in the border counties in Iowa compared with the border counties in Illinois following a stay-at-home order that was implemented in Illinois but not in Iowa.

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Article Information

Accepted for Publication: May 11, 2020.

Published: May 15, 2020. doi:10.1001/jamanetworkopen.2020.11102

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Lyu W et al. JAMA Network Open.

Corresponding Author: George L. Wehby, PhD, Department of Health Management and Policy, The University of Iowa, 145 N Riverside Dr, 100 College of Public Health Bldg, Room N250, Iowa City, IA 52242 (george-wehby@uiowa.edu).

Author Contributions: Mr Lyu and Dr Wehby had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Wehby.

Acquisition, analysis, or interpretation of data: Both authors.

Drafting of the manuscript: Both authors.

Critical revision of the manuscript for important intellectual content: Wehby.

Statistical analysis: Both authors.

Administrative, technical, or material support: Lyu.

Supervision: Wehby.

Conflict of Interest Disclosures: None reported.

References
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Office of the Governor of Iowa. Gov. Reynolds signs new proclamation continuing State Public Health Emergency Declaration, ordering additional closures. Published April 6, 2020. Accessed April 20, 2020. https://governor.iowa.gov/press-release/gov-reynolds-signs-new-proclamation-continuing-state-public-health-emergency-3
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Rodriguez  B . Iowa Board of Medicine, physicians' group ask Gov. Kim Reynolds to issue mandatory order for Iowans to stay home during outbreak. Des Moines Register. Published April 3, 2020. Accessed April 20, 2020. https://www.desmoinesregister.com/story/news/health/2020/04/03/coronavirus-board-medicine-recommends-iowa-governor-issue-mandatory-shelter-place/2940467001/
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