COVID-19 Update: Inside Denver's New Rules and Risks

At a May 5 press conference, Mayor Michael Hancock and a cadre of officials previewed new rules going into effect prior to and after Denver's current stay-at-home mandate over COVID-19 expires at the end of Friday, May 8. The city subsequently released a more specific outline of regulations and recommendations about a phased-in reopening, and they're abundant.

But even as some restrictions are slowly lifted, others will remain in place at least through May 26, when the latest order ends.

Meanwhile, responses from the Denver Department of Public Health and Environment make it clear that there's a lot we still don't know about the current spread of the novel coronavirus, much less what may happen in the future.

Here is Denver's list of businesses that may reopen on Saturday, May 9, as long as they follow "strict social-distancing guidelines and precautions to limit the number of employees and customers on site at a given time":

• Non-critical retail such as clothing, home goods, cell phone (with 50 percent employees and six-foot social distancing)
• Personal services such as hair/nail salon, tattoo, pet groomer and personal trainers (with ten or fewer people in a single location or max of 50 percent occupancy, whichever is less; by appointment only, no walk-ins; strict requirements about PPE and distancing)
• Non-critical offices (with 50 percent employees)
• Field services such as in-person real-estate showings
• Limited healthcare (with ten or fewer people in a single location or max of 50 percent occupancy, whichever is less; by appointment only, no walk-ins)
• Post-secondary education

Businesses that will remain closed in Denver until further notice include:

• Sit-down service in restaurants, bars, coffeehouses and other places of public accommodation
• Movie theaters
• Live-performance theaters
• Concert venues
• Sports arenas
• Gyms (with very limited exceptions)
• Shopping malls (except for stores that have public entrances/exits to the outside)
• Outdoor recreation facilities such as children’s playgrounds and tennis and basketball courts
• City recreation centers and libraries

In order to stay open, a business in one of the permitted categories is required to do the following:

• Create special hours for vulnerable individuals when practical
• Limit the number of on-site customers to continuously maintain six-foot distancing
• Provide hand sanitizer and wipes at entrances to the greatest extent possible
• Use contactless payment solutions when possible
• Create signage regarding health protocols
• Deputize a workplace coordinator to address COVID-19 issues
• Maintain six-foot separation between employees and discourage shared spaces
• Clean and disinfect all high touch areas
• Post signage for employees and customer on good hygiene
• Ensure proper ventilation
• Avoid meetings or groupings of more than 10 employees, clients or customers
• Implement symptom monitoring protocols such as temperature checks
• Eliminate, or regularly clean and disinfect, any items in common spaces
• Require employees with symptoms to stay home
• Accommodate employees who are vulnerable individuals
• Provide flexible options for employees with child or elder-care obligations
• Provide appropriate PPE, like gloves, masks, or face coverings, if employees are unable to provide their own

In addition, large businesses, defined as those with fifty or more employees, must take these extra steps:

• Create signage regarding health protocols
• Implement symptom monitoring protocols such as temperature checks
• Close common areas to disallow for gatherings of employees
• Conduct mandatory cleaning and disinfecting protocols
• Implement social distance protocols

Recommended, but not mandated, are these procedures:

• Implement symptom monitoring protocols such as temperature checks
• Limit or discourage in-person meetings
• Discourage use of shared spaces such as break rooms and meeting rooms
• Consider using separate entrances and exits, with staff members counting visitors to control the number of guests at one time
• Install plastic protective shields to provide protection between employees and customers 

While businesses begin to reopen, Denver is also focusing on testing. Residents can learn about the closest testing location by visiting the city's COVID-19 web page or dialing 311. People unable to make it to a site may qualify for a home visit from a mobile unit dubbed Wellness Winnie, which hit the streets on May 5, with more units expected to roll out soon. However, a doctor's order is still required for a test to be authorized at those sites.

Meanwhile, the city is working to improve contact tracing. Staffers will "interview people who have been diagnosed with COVID-19 to determine who they may have been in close contact with during the time they were considered to have been infectious" and "warn these individuals, or contacts, of their potential exposure as quickly and sensitively as possible." To protect patient privacy, such contacts will not be told the identity of the person who may have exposed them — and they'll be offered resources and support. As for those who test positive, they will be provided with "education, information and support to understand their risk, what they should do to separate themselves from others, how to monitor themselves for illness, and the possibility that they could spread the infection to others even if they themselves do not feel ill."

These actions are key, given what we learned from a DDPHE spokesperson corresponding via email regarding the actual number of cases in the city:

Because testing is far from universal, many individuals are presumed to be positive — but not officially. The DDPHE "focuses data collection on positive (lab-confirmed) COVID-19 cases. This is because a lab-positive result is reportable to the health department. Presumptive positives are not reported to the health department, and so we may not know about them. Ideally those are folks who are well enough that they didn’t need to seek care in-person, and will recover at home."

The spokesperson adds, "We do not necessarily track presumptive positives from a data collection standpoint. This is because a presumptive positive (not lab tested) isn’t reportable to the health department and because we may not get enough information to identify trends." Moreover, "It is extremely likely that presumptive positives might not be confirmed. Those people may have called a doctor, listed symptoms and been classified as presumptive positive based on symptoms alone. If they recover, they or their doctor may determine they don’t need testing."

Further blurring a precise understanding of COVID-19's scope in Denver is test accuracy. "We don’t currently factor false negatives into our data," the DDPHE rep acknowledges, "but as more information becomes available, we may. Right now, the false negatives we are most aware of are those from serology tests, known also as antibody tests. The true accuracy of those tests is still to be determined through additional, larger studies by the manufacturers. In addition to COVID-19 infection testing (this is not an antibody test) through their medical provider, people with COVID-19-like symptoms or a believed exposure to someone with symptoms are directed to self-isolate, so ideally anyone, regardless of test result, should be isolating themselves until their symptoms resolve or the incubation period has elapsed."

As for the true number of Denver residents infected by the novel coronavirus, the DDPHE spokesperson writes, "Every day we see more research about undetected cases, and the percent associated. As testing expands, we fully expect to see an increase in case numbers. There have been multiple assessments conducted on the percent of positive cases we have been able to identify, both within the U.S. and in other countries. One estimate is that approximately 30 percent of cases are detected."

There's uncertainty regarding the city's death toll, too: "Denver’s Office of the Medical Examiner tracks mortality in multiple ways to attempt to build the most complete and accurate picture. A 'confirmed' case is one that is listed as cause of death on a death certificate. This may or may not be laboratory confirmed."

Even universal testing isn't a panacea, the DDPHE representative maintains: "It would be helpful to know who in Colorado is infected with COVID-19 and is a risk to spreading it to others. However, a single test on any given day may not provide the whole picture. A person may have been exposed, not yet experiencing symptoms, and not have a viral load yet detectable by the testing. If they get tested now, we can’t guarantee they wouldn’t test positive tomorrow or the next day. This is because of incubation period. Additionally, if we tested everyone, we would need great compliance to reduce transmission — each positive case would need to stay home and away from families until 72 hours after their symptoms have resolved. Rather, it is more likely that in the future we have a COVID-19 test used in a similar fashion as the flu test, where only those who are sick enough to need medical attention go to the doctor and get tested to determine a treatment course."

Because the incubation period for the virus is between two and fourteen days, "what we hope to get to through contact tracing is that for every positive case, we can contact their close contacts (physically within six feet for a prolonged time) and recommend they quarantine themselves for fourteen days since they were exposed. Ideally we would want to test all of these contacts."

The DDPHE isn't recommending that asymptomatic people be tested right now, in part because of current testing shortages. The exception to that rule are those who may have had "an exposure through work, such as a health-care worker. Additionally, people can most easily access testing through a medical provider, which would require risking exposure to go to the doctor or testing site. The best approach is to keep following the social distancing guidance and to wear a face covering whenever you are around other people."

It's "too soon to tell" if the infection has peaked in Denver, the DDPHE spokesperson concedes: "We are monitoring multiple different indicators, such as hospitalizations, and we are optimistic that because of social distancing and stay-at-home orders, we may not see a dramatic rise in hospitalizations. However, as more testing becomes available, we will likely see the data trend upward due to the increase in testing." That goes for a potential second wave of infections, which many models predict for later this year across the country.

The department is "aiming for 100 percent compliance in use of face coverings, especially as businesses prepare to reopen. Even just a few people can create a huge ripple."

We should know more about whether that ripple turns into something bigger for Denver a few weeks after May 9.