March 27, 2020 Dear Tennessee Municipality and County Mayors, Tennessee, along with the rest of the world, is facing an unprecedented health care challenge in the COVID-19 pandemic. The scenes that we are witnessing from Italy and other countries in Europe are difficult to imagine. In our own country, the greater New York City area has become the epicenter of this scourge and the loss of life and level of illness there is only beginning to be appreciated as the health care systems in our largest American city are beginning to be overwhelmed. In order to attempt to slow the spread of COVID-19 in Tennessee, the Tennessee Medical Association would recommend each of you to request authority from the Governor to allow you to issue a Stay at Home or similar order for your jurisdiction, like those now in place in Nashville, Memphis, Knoxville and Franklin. The only effective mechanism to slow the virus to prevent an overwhelming influx of critically ill patients in our health care system is increased social distancing, which can be enhanced by such orders. Ideally, we would recommend that these orders close all non-essential businesses, limit all non-essential activities and gatherings of any size, and impose a 14-day self-quarantine on anyone entering our state from another state or country with few exceptions, such as our trucking and delivery systems. In the absence of a state-wide order at this point, your local orders can help protect our population and save lives. Tennessee’s number of total positive cases continues to rise at an alarming pace with 957 reported by the Department of Health yesterday and an average of over 120 new cases per day the past six days. Three people in Tennessee have died from COVID-19. While the elderly and those with chronic health care problems like heart disease, lung disease, cancer, and immunosuppression appear to be at higher risk, we are seeing young healthy people requiring intensive care support in our hospitals as well. Our doubling time for cases is just under four days, meaning that in less than four days we will have twice as many cases as we do today. While only ten counties are reported to have over ten cases yesterday (Davidson 203, Shelby 147, Williamson 70, Sumner 43, Hamilton 28, Rutherford 27, Knox 26, Robertson 20, Wilson 13 and Putnam 11), even the smallest counties in Tennessee will likely see significant numbers in the near future because each infected person is currently estimated to be infecting more than three other people in Tennessee. Davidson County only had ten cases two weeks ago on March 13. In addition, since testing has been March 27, 2020 Page 2 limited by scarcity of supplies and delays in test results, the actual number of COVID-19 cases is likely much higher than we are reporting. While we realize the detrimental effects Stay at Home orders will have on your local communities, without action now COVID-19 threatens to disrupt our businesses and lives much longer and in more profound ways if allowed to spread at this pace. While many cases are mild and self-limited, up to 15% of cases require hospitalization, 10% in intensive care units, and 5% needing ventilators, and these effects are usually seen in the second week of illness. What we do now will impact what we face in April and May. Stay at Home orders are our best chance to buy time, and implementation now with fewer cases rather than later with overwhelming cases seems most prudent. We need time to establish effective and reliable supply chains for personal protective equipment for our health care workers, to improve availability of testing kits and reagents, to limit the surge on our health care system and obtain more ventilators, and to attempt to develop and study effective therapies to treat those who are ill. While these facts and recommendations seem alarming, most of us will survive this pandemic without prolonged difficulty. But for the sake of our elderly and those younger patients who will develop a life-threatening illness from COVID-19 we must act to do what we can to slow this virus now to prevent excessive deaths and disability. Thank you for your consideration of this urgent matter. We need to trust the advice of our best infectious disease and epidemiological physicians to guide us through this difficult time and do what we can now to protect our critical care and hospital physicians who will be caring for increasing numbers of seriously ill patients in the days to come. All the physicians of the Tennessee Medical Association stand ready to face this challenge with you, but any actions you can do now to protect us and our ability to care for the citizens of this great state will be greatly appreciated. Sincerely, Elise Denneny, MD President Tennessee Medical Association Chattanooga Hamilton County Medical Society Coffee County Medical Society Franklin County Medical Society Knoxville Academy of Medicine Maury County Medical Society Memphis Medical Society M. Kevin Smith, MD, PhD President-Elect Tennessee Medical Association March 27, 2020 Page 3 Montgomery County Medical Society Nashville Academy of Medicine Stones River Academy of Medicine Upper Cumberland Medical Society Cannon, Clay, Cumberland, DeKalb, Fentress, Jackson, Macon, Overton, Pickett, Putnam, Smith, Van Buren, Warren and White Counties Williamson County Medical Society Wilson County Medical Society Tennessee Academy of Family Physicians Tennessee Association of Long-Term Care Physicians Tennessee Chapter of the American Academy of Pediatrics Tennessee Chapter of the American College of Cardiology Tennessee Chapter of the American College of Emergency Physicians Tennessee Chapter of the American College of Physicians Tennessee Geriatrics Society Tennessee Osteopathic Medical Association Tennessee Psychiatric Association Tennessee Radiological Society Tennessee Society of Anesthesiologists