Associations of Stay-at-Home Order Enforcement With COVID-19 Population Outcomes: An Interstate Statistical Analysis

In the United States, state governors initially enacted coronavirus diseases 2019 (COVID-19)-mitigation policies with limited epidemiologic data. One prevailing legislative approach, from March to May 2020, was the implementation of "stay-at-home" (SAH) executive orders. Although social distancing was encouraged, SAH orders varied between states, and the associations between potential legal prosecution and COVID-19 outcomes are currently unknown. Here, we provide empirical evidence on how executive enforcement of movement restrictions may influence population health during an infectious disease outbreak. A generalized linear model with negative binomial regression family compared COVID-19 outcomes in states with law-enforceable stay-at-home (eSAH) orders versus those with unenforceable or no SAH orders (uSAH), controlling for demographic factors, socioeconomic influences, health comorbidities, and social distancing. COVID-19 incidence was less by 1.22 cases per day per capita in eSAH states compared with uSAH states (coefficient = -1.22, 95% confidence interval (CI): -1.83, -0.61; P < 0.001), and each subsequent day without an eSAH order was associated with a 0.03 incidence increase (coefficient = 0.03, 95% CI: 0.03, 0.04; P < 0.001). Daily mortality was 1.96 less for eSAH states per capita (coefficient = -1.96, 95% CI: -3.25, -0.68; P = 0.004). Our findings suggest allowing the enforcement of public health violations, compared with community education alone, is predictive of improved COVID-19 outcomes.