San Francisco seems to have flattened the curve, but an outbreak at a nursing home, jail, or homeless shelter could change everything

• San Francisco seems to have flattened the curve, avoiding the surge of COVID-19 infections that devastated New York.
• Local doctors say an outbreak in a nursing home, homeless shelter, or jail could spread into the larger community and overwhelm Bay Area hospitals.
• Many of these living facilities are already struggling to contain the spread of the virus.
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So far, San Francisco has avoided the flood of coronavirus cases that overwhelmed New York hospitals in March and April. The city's case count hovers below 1,500. Daily hospitalization rates have been steady for about two weeks.

"I think we have sufficient evidence at this point to suggest that the curve has been flattened from the sort of doomsday scenario that could have been," Dr. Jahan Fahimi, the medical director of the ER at the University of California, San Francisco, told Business Insider.

The city's success seems largely due to its early shutdown. The San Francisco Bay Area became the first to impose strict lockdowns when, on March 16, six counties ordered all non-essential businesses closed and asked residents to stay home. New York, by contrast, didn't issue its stay-at-home order until March 23.

But local doctors warn that San Francisco could lose its tenuous grasp on the virus's spread at any moment, even before it lifts its stay-at-home restrictions, which have been extended through May.

"At any point, an outbreak within a nursing home, within a homeless shelter, within a jail — all of which have kind of already happened — could reignite the fire," Fahimi said. "So we're optimistic that the number of cases that we're seeing is not spiking, but worried that it always could."

Across the city, ongoing outbreaks threaten to leave these facilities, spread through the wider community, and undermine the lockdown's success.

The city's biggest homeless shelter has re-opened after a large coronavirus outbreak

San Francisco's largest homeless shelter, Multi-Service Center South, has been home to one of its largest COVID-19 outbreaks.

In early April, 95 guests and 10 staff members tested positive, most of whom were asymptomatic. That was a majority of the roughly 150 people staying in the shelter at the time, according to ABC 7 News. The city shut down the facility for cleaning and moved its guests to private hotel rooms, but opened the shelter back up last week. It will now comply with six-foot distancing guidelines, ABC7 reported.

"It's impossible for people to isolate when they're living in a large group, sharing a bathroom and sharing eating spaces with large groups of people," Jenny Friedenbach, director of the Coalition on Homelessness, told CityLab. "The have-nots are basically put into large congregate settings and locked down there until they're able to pull out the dead bodies."

Outbreaks in such close living quarters don't just pose a danger to their residents. When people who have contracted the novel coronavirus leave the facility, that threatens efforts to control the virus across the entire city.

"If it spreads rapidly in that group and then disperses out into the community, you kind of start the clock all over again," Fahimi said.

Experts are calling for widespread testing at nursing homes and jails, too

Nursing homes have been hubs for deadly outbreaks across the US, and the Bay Area is no exception.

According to a report from the California Department of Public Health, 31 nursing homes in the Bay Area have confirmed cases in residents or healthcare workers.

At one such facility in San Francisco, the Central Gardens Convalescent Hospital, 67 residents and workers have tested positive for COVID-19, and four have died, the San Francisco Examiner reported.

"We've been congratulating ourselves in California for having flattened the curve, but social distance is a luxury in a nursing home the same as it is in a prison," Mike Dark, a staff attorney with California Advocates for Nursing Home Reform, told Kron4. He added that nursing homes' reports "frighteningly [are] just the tip of the iceberg because the data is self reported and we know many facilities are not telling the state the problems that they are having."

Jails are also an area of concern. Two inmates at the San Francisco County Jail have tested positive for the virus. Across the bay, at Santa Rita Jail in Alameda County, 34 inmates and two staff members are infected. Three of those inmates are no longer in custody.

Before Bay Area counties open back up, experts say they will need to implement widespread testing and contact tracing to catch and contain new outbreaks — both in close-quarters living facilities and in the community at large.

"I really hope, before we relax things, that we have all the things in place that we need to detect any surges if they're happening and to respond very, very quickly," Dr. Lisa Winston, an epidemiologist at Zuckerberg San Francisco General Hospital and Trauma Center, told Business Insider.

"Our hospitals in San Francisco and the Bay Area are not at their maximum capacity, but if there was unmitigated spread I think there is the possibility of being overwhelmed."

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