As states began the process of reopening over the last six weeks, some areas across the country saw an uptick in positive COVID-19 cases. As a result, some reopening plans have been stalled or, in some cases, walked back.

For those still able to move forward with their reopening procedures, however, the attention is now turning toward how they can remain reopened and avoid another shutdown. To achieve as much, most local health officials agree that keeping gatherings small, wearing masks and maintaining six feet of social distance are the keys to ensuring a safe path forward.

“If we do all these things, we can keep the spread contained to a point where we can continue to have things open,” Dr. Joshua Meyerson, the medical director for three district health departments in Northern Michigan, said this week. “Our children should be in school in the fall, physically at the school, and we can keep our economy and our businesses open and operating. I think that’s really important for people to understand. It’s up to all of us.”

Officials in 11 states discussed how experts believe they can continue their reopening process all while battling an increased number of COVID-19 cases. What’s next for these states? What do they recommend doing to avoid backsliding in the fight against the outbreak? The following is what we found.

MICHIGAN

In Michigan, Gov. Gretchen Whitmer instituted a requirement for wearing masks in all retail establishments and indoor businesses on July 13. In an address on Wednesday, she urged residents to wear masks in public, after the state reported its largest increase in confirmed COVID-19 cases in nearly two months. Whitmer stated she may be forced to add more restrictions if that trend continues.

The majority of the state is in phase four of reopening, which is considered “improving,” but Northern Michigan, including the Upper Peninsula, is now in phase five, the “contained” phase, which is one step away from “post-pandemic.” The state was in phase three during the shutdown, which lasted a little more than two months for Northern Michigan and longer for the lower parts of the state.

Dr. Joshua Meyerson is the medical director for three district health departments in Northern Michigan, including District Health Department No. 4, which includes Alpena County.

“Our rate of positive tests are low — below 3 percent,” Meyerson explained as to what phase five means in Northern Michigan. “We’re doing an adequate number of tests … and our number of new cases is also low. That’s a good place to be, containing these cases.”

In order to continue moving in the right direction, Meyerson said that “we have to realize that we all have a responsibility to reduce the risk of widespread or increased transmission of this disease.”

He added that in the last two weeks, the Northern Michigan region has seen an increase in cases, which he attributed mainly to summer travel.

“As a region, although our percentage of positive test results are still low, they have trended up quite a bit in the last few weeks, and our number of cases have really gone up significantly over the last two weeks,” Meyerson said. “Some of these cases are our seasonal residents and our guests who are up here for vacation. There are also local residents who live here who have traveled and brought it back with them. When there’s more movement of people, there are more cases.”

He said we need to reverse that trend, and fast.

“The trend that we’ve seen in the last two weeks is concerning, and if we can’t get that under control I think that could really impact our ability to move forward as a region,” Meyerson said.

MINNESOTA

In Minnesota, face coverings are highly recommended but not yet mandated as of Thursday. Cases remain lower than the are in other states, but they are on the rise.

“We are seeing an uptick in cases, and that’s concerning,” said Tim Langer, public health sanitarian for Faribault and Martin counties. “People need to realize that this is a virus that can get out of hand very quickly, unless precautions are taken. And we’re seeing that in different states — in Florida, and Texas, Arizona, California, Georgia. Those states are seeing huge increases in the number of cases.”

In order to prevent that, he said physically distancing from each other, using common sense and avoiding large groups of people are all part of the measures that need to be taken to reverse the upward trend.

“Doing outdoor activities rather than indoor activities,” Langer said. “The rate of infection is much less outdoors, due to the wind patterns and that sort of thing.”

When you can’t be outdoors, he says to mask up.

“When you’re in groups and unable to social distance, people should be wearing masks to prevent the droplet spread of the virus,” he said.

He said the number of younger kids who are getting the virus is concerning, because they can be carriers and then pass it on to more vulnerable family members, such as grandparents. Children need to be shown how to properly wash their hands and use hand sanitizer to help prevent the spread, he said.

“We need everybody to do their part to prevent the spread of this virus,” he said.

OHIO

As COVID-19 cases continue to rise, health officials are focusing on informing communities and slowing the spread of the virus.

“Improvement within the county regarding COVID-19 can only occur if the residents of each community choose to take responsible steps to slow the spread,” Huron County Public Health information officer Melanie Myers said. “It is crucial that everyone comes together to follow the recommendations and orders of Gov. Mike DeWine and the Ohio Department of Health.”

Those measures include staying home when sick, wearing masks in public, banning mask gatherings and limiting unnecessary public exposures.

“If, as a community, we come together and take these steps, we can limit the county’s exposure to this disease and can make a tremendous impact on reducing the number of those infected and potential unnecessary deaths,” she said.

Myers added that she didn’t want to speculate on if there will be another state-wide shutdown, but as they continue to see an increase in cases, they are encouraging the community to take necessary steps to prevent any further potential mandates.

“During these unprecedented times, it is of utmost importance to take care of one another and make decisions that are in the best interest of our community rather than what is best for our personal interests,” she said. “When choosing to leave home for unnecessary needs or duties, residents should remember that the decision made today can impact a child, pregnant woman, grandparent or loved one in the coming weeks.”

Kristofer Wilster, director of environmental health for Trumbull County Combined Health District, said the further spread of the virus is of the utmost concern. He said community members should continue to wash their hands, use hand sanitizer, social distancing and wear masks in public.

In the Columbiana County Health District, public information officer Laura Fauss said their major concerns are residents not wearing masks and not getting preventive care like vaccinations, checkups or mammograms.

She said to prevent another shutdown, residents should follow the same measures they have been following — wearing a mask, keeping six feet between yourself and others, washing hands, cleaning high touch surfaces regularly and not touching your face.

Fauss said that if the cases increase to the point where they are close to overwhelming hospitals, there will be another shutdown.

“Our epidemiologist likened the situation that we are in right now to someone that has been taking a class,” Fauss said. “They worked hard all year on homework, studying and doing special projects (stay at home orders and gradual reopening) and now we’re at the final exam. If we fail the final exam, all the hard work we have done will be lost. We must continue to work hard at stopping the spread of this disease.”

At Firelands Regional Medical Center, Dr. Scott Campbell said the hospital’s concerns are running efficiently and safely for patients while being mindful of the presence of COVID-19.

“We have spent countless days since the initial news that COVID-19 existed, preparing our hospital, employees and staff for combating whatever this virus sends our way,” Campbell said. “Thanks to the initial social distancing, the curve flattened, which gave us time to adequately prepare.”

Norwalk safety-service director Ralph Fegley said people have been doing everything to keep from going into another shutdown.

“I don’t see anything different we can do — pray maybe,” he said. “I don’t anticipate (another shutdown). Maybe I’m being optimistic, but I just don’t see it.”

PENNSYLVANIA

As cases started climbing again in parts of Pennsylvania, Gov. Tom Wolf announced more restrictions during a Wednesday briefing. He said cases are on the rise due to people ignoring guidelines on social distancing and wearing masks in public, along with out-of-state travel and “a lack of national coordination.”

“We don’t want to become Florida,” Wolf said during the briefing. “We don’t want to become Texas. We don’t want to become Arizona. We have got to act now.”

In an executive order, Wolf mandated that restaurants and bars cannot sell alcohol for on-site consumption unless it’s with a meal. They are also to operate at 25 percent occupancy while prohibiting bar seating.

“We have seen these efforts work during the first wave in the spring, and they will work again if we all do our part,” Wolf said during the briefing. “I know you are eager for life to get back to normal, and I am, too.”

Earlier this month, Wolf’s administration mandated that people wear masks when in public. He reiterated the importance of masks last week.

“We want people to spend time together, but to do so while practicing social distancing and wearing masks when required,” he said. “When you leave your home and you’re not participating in an outdoor exercise, wear a mask.”

The state’s Department of Health Secretary Rachel Levine challenged Pennsylvanians to “make a choice” and do what they can to prevent the spread of COVID-19 when it comes to masks and social distancing.

KANSAS

In Lawrence, Kansas, health officer Dr. Thomas Marcellino said mask usage is “by far” the best thing people can do to prevent the spread of the virus. He also recommended that citizens follow all health orders, social distance and wash their hands frequently.

He recommended keeping one’s circle of contacts small, and that if someone engages with a larger group of people, the event should occur outdoors with six feet of separation or with masks. When venturing into the community, Marcellino said people should always have a mask and hand sanitizer available.

Other specific advice from Marcellino included avoiding unnecessary handling of items at the grocery store – try not to pick something up unless you plan to buy it – and planning out one’s errands so as to reduce the number of stops in order to curtail exposure.

WEST VIRGINIA

Rising numbers of COVID cases have taken some wind out of the sails of the state’s recovery, with Gov. Jim Justice reimposing a handful of restrictions last week.

Justice ordered the cancellation of summer fairs and festivals, which had received a green light to resume earlier this month. He also lowered the limit on group gatherings from 100 people to 25 and ordered bars in Monongalia County, the home of West Virginia University, to be closed for 10 days due to the number of cases there.

“I think he (Justice) would say he is really trying to thread that needle appropriately” and balance the health of the citizens and avoid as much as possible the economic harm that could come with closing things down again, said Dr. Clay Marsh, who heads up the state’s coronavirus response.

The number of positive cases in West Virginia doubled over the last two weeks, Marsh said. The rate of positive tests climbed over 3 percent in recent days from less than 1 to 1.2 percent two weeks ago, he said.

To get those numbers moving in the opposite direction, he said, West Virginia residents need to practice social distancing and wear masks, something Justice made mandatory – albeit without penalties – two weeks ago. The state must also continue to increase testing, which will provide data that allows decision-makers to tailor their approach to combating the virus.

“You don’t want to take a hammer to fix something that has a very specific need,” Marsh said.

Expanded testing can identify “super-spreaders” who don’t realize they’re infected because they are asymptomatic or presymptomatic, Marsh said.

While “most people do OK with COVID,” Marsh said, West Virginia has a number of populations who are at higher risk for problems from the disease due to factors including age, underlying health conditions like obesity and heart disease and even smoking or the use of e-cigarettes.

Although younger people are thought to be less at risk for serious health effects, the long-term effects of the disease are still unknown, Marsh said. Information about the virus continues to evolve, with recent indications suggesting it is more of a vascular disease than a disorder of the lungs.

“People with blood type A (can) have much worse outcomes than people with blood type O,” Marsh said. “The blood is clotting throughout a lot of people’s bodies with COVID” leading in some cases to mild strokes or heart attacks, he said.

VIRGINIA

Following the CDC guidelines on masks, social distancing, sanitizing, and self-isolating, is exactly what the Virginia Department of health are asking of Virginians, according to the department’s public information officer, Julie Grimes.

“We know that everyone has a part in helping to stop the spread or at least slow the spread of COVID-19,” she said.

The state has seen some spikes in cases in certain areas across the state, including the Virginia Beach area, Grimes said.

“They believe the spikes we’re seeing in the beach areas are because of people gathering in groups,” she said. “There have been a number of reports of people not wearing masks while in places where they should be wearing masks.”

Due to the spikes, Gov. Ralph Northam has “stepped up enforcement” of mask-wearing guidelines, Grimes said.

“Unless you have a medical reason for not wearing a mask, you are to follow executive orders that say if you are inside a building, you should wear a face covering unless you are eating or drinking,” Grimes said.

In the beginning of the pandemic, “enforcement” was more of an opportunity to educate, Grimes said. Health Department inspectors would visit different businesses and remind people to wear masks and educate people about the virus.

“Now, we’re in Phase 3, and everyone should be aware of the fact that masks are important,” Grimes said.

Northam’s “stepped up enforcement” includes allowing the state’s Alcoholic Beverage Control Authority and the Department of Agriculture to conduct “unannounced visits” to establishments like bars and restaurants to ensure people are following the guidelines, Grimes said. Should there be a violation, those agencies have the authority to offer consequences like a court order or even revoking a license to sell liquor.

MARYLAND

Most of the state is in Stage 2 of Gov. Larry Hogan’s Roadmap to Recovery plan. The keys to moving toward Stage 3 are fairly simple, said Dr. Randall Culpepper, medical director of the Frederick County Health Department.

Those keys? Practice social or physical distancing, telework to the maximum extent possible and wear a mask.

“If people are not following those general principles … we’re going to go backwards,” Culpepper said.

Frederick County is averaging 15 or 16 new cases a day, a slight increase in recent weeks, Culpepper said. The seven-day rolling average for positive tests was about 2.4 percent, up from 2 percent a week earlier, but below the 4.6 percent rate statewide, he said.

Culpepper said increased testing could be the reason for the higher numbers and slight positivity rate increase. But additional testing alone can’t explain bigger jumps in other parts of the country.

“That isn’t why,” Culpepper said. “You would expect to have the same positivity rate” even if there were more individual cases detected.

Dropping in Frederick County are the hospital census and the number of deaths, with just four fatalities recorded in the past five weeks. State statistics show the county with a total of 113 laboratory-confirmed COVID-19 deaths. Not that long ago, Culpepper said, there might have been four or more deaths in a single day.

“The number of days with zero on it makes my heart sing,” he said.

Culpepper said many people in Frederick understand the importance of wearing masks. Face coverings are required by the state in all retail establishments, but he said he knows there are places — some local bars, for example — where that’s ignored.

“I’m dumbfounded by that,” Culpepper said. “Why wouldn’t you want to take those precautions that will keep my business open?”

But Culpepper said he believes most people are willing to wear masks, which he noted provide more protection for those around an individual than the actual mask-wearer.

“As frustrated as I get with those who don’t, I’m really pleased with those who do,” he said.

NEW HAMPSHIRE

As the state reopens, people are beginning to enjoy returning to work in-person and visiting their favorite restaurants.

As a result, Bobbie D. Bagley, director of the Division of Public Health and Community Services for the city of Nashua, said restaurants are the types of places where caution should be used the most.

“We need to have our economy, we need people working and enjoying themselves,” she said. “Because those are places where larger groups are when they go out, we need to make sure they have their masks and maintain social distancing.”

Bagley said her main concern is making sure people remain vigilant about reducing the spread of infection.

“Stay home when you’re sick,” she said. “People who don’t have signs or symptoms, or they don’t consider themselves sick but they’re sneezing or have a tickle in their throat, some of those are signs of infection that happen before a fever. You shouldn’t assume it’s allergies. If you have something mild, the best thing they can do is get tested to rule [COVID-19] out.”

Bagley also said people should continue to maintain at least six feet between people who do not live in their household, wear masks in public, clean high-touch surfaces and wash their hands.

“People really hate this mask thing, but it really is one of the cheapest ways we can help each other throughout this,” Bagley said. “If you can’t social distance and you really want to enjoy yourself out in the public, please wear your mask.”

She said the numbers of positive COVID-19 cases have to stay down to keep hospitals from getting overwhelmed.

“If we can maintain a flattening of our curve and have some personal responsibility with everyone working together, we can prevent another shutdown,” Bagley said. “If we continue to do the things we’re doing, maintaining what public health is asking, we can prevent another shutdown but it’s going to take us all working together.”

UTAH

In Ogden, Utah, health department public information officer Lori Buttars said that though Utah’s reopening plan is phased in three colors – red, yellow, and green – one’s risk of contracting COVID-19 does not alter with a change in color. Rather, each phase comes with more personal responsibility.

Ogden is currently in the yellow phase of reopening, Buttars said. She then added that in trying to reopen the community safely, they are encouraging residents to wear masks, stay six feet away from one another, avoid groups larger than 50 and stick with family members if someone is going to a public event.

Green is the least restrictive phase, whereas red is the most restrictive.

Buttars also disseminated information about how citizens can protect themselves while getting gas. The Weber-Morgan Health Department recommends using disinfecting wipes on handles and buttons on gas pumps prior to touching them.

HAWAII

In Maui County, Hawaii, numbers are lower than they are in other states, and they’d like to keep it that way. There is currently a statewide mandated 14-day quarantine on visitors traveling to the islands.

Chris Sugidono is the public information officer for Maui County, which covers three Hawaiian Islands.

“Hawaii, we’re very fortunate, because cases, compared to other states in the United States, we’re in a much better situation,” Sugidono said.

He reiterated the three things that everyone should continue to do to keep the numbers low: wear face coverings, maintain social distance, and practice good hygiene.

He added that although Hawaii relies highly on its tourism industry, he still recommends that people not travel unless they need to.

“Maybe put off the trips to Vegas,” he said of Maui County residents, adding that they have to return home at some point, which increases the risk for spreading the virus.

He said Maui County residents have been doing a good job taking precautions.

“I think people understand what everybody is trying to do,” Sugidono said. “Especially with wearing face coverings — it’s not just for your protection, it’s for the protection of the people around you. And studies have shown it dramatically decreases your chances of spreading the virus.”

_______________

Ogden Newspapers reporters Evan Bevins, Darby Hinkley, Katie Anderson, Lauren Fox and LynAnne Vucovich contributed to this report.