The emergence of novel infectious diseases, such as severe acute respiratory syndrome (SARS) and H1N1 influenza pandemic, has consistently exposed the socioeconomic, physical, and preparedness weaknesses in modern society. ^{Reference Keesing, Belden and Daszak1} For instance, 1 study analyzed the financial impact of a mild influenza pandemic on the global economy, which estimated a cost of close to 0.8% of gross domestic product, which was equivalent to US $330 billion. ² Fortunately, global trends of emerging infectious diseases have been strongly correlated with several identifiable factors – human density and the distribution of wildlife biodiversity. ^{Reference Keesing, Belden and Daszak1} Thus, the targeting of surveillance efforts to specific “hotspots,” using spatially explicit models, can allow for better allocation of resources and preparation for disease outbreaks. ^{Reference Keesing, Belden and Daszak1} However, preparation for outbreaks continues to present challenges that contribute to the negative socioeconomic and health effects of pandemics.

In the wake of recurrent pandemics in the 19th and 20th centuries, the World Health Organization (WHO) published its first pandemic plan in 1999, which focused primarily on surveillance, yet minimally discussed plans for response or communication efforts that are necessary for pandemics. ^{Reference Gust, Hampson and Lavanchy3} In response to the 2002–2004 SARS pandemic, the Department of Health and Human Services and White House strategy for a pandemic response ultimately recognized the need for increased planning efforts, which resulted in the 2006 Pandemic and All-Hazards Preparedness Act – calling for the critical review of state pandemic preparedness plans. ^{Reference Iskander, Strikas and Gensheimer4} All combined efforts fundamentally led to the uptake of the 4 pillars of pandemic response: surveillance, vaccine and antiviral development, emergency response, and communication. ^{Reference Gensheimer, Fukuda and Brammer5}

Although the need for local and state-based pandemic response plans has long been recognized as essential, ^{Reference Iskander, Strikas and Gensheimer4} many communities continue to lack pandemic preparedness. One study indicated that only 17 states (35%) explicitly discussed the use of voluntary self-isolation and only 15 states (31%) discussed the use of institutional or household quarantine as measures for reducing the morbidity and mortality of pandemics. ^{Reference Holmberg, Layton, Ghneim and Wagener6} Likewise, the link between partisan interests and the coronavirus disease 2019 (COVID-19) outbreak has recently come to fruition as Republican voters reported less concern. ^{Reference Barrios and Hochberg7} The current pandemic outbreak of COVID-19, a result of the virus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), offers a new opportunity to evaluate the pandemic response preparedness of US states. Following the 2014–2015 Ebola epidemic in Sierra Leone, West Africa, a recent study found that public awareness and knowledge of Ebola were high, yet awareness of preventive measures was lacking, which likely impacted the transmission rate. ^{Reference Jalloh, Sengeh and Monasch8} Therefore, we posit that 1 method in monitoring preparedness during the COVID-19 pandemic is through the analysis of public interest in prevention techniques. Thus, the objective of this study was to analyze public interest in COVID-19 preventive measures and to identify and describe variables that were associated with timely stay-at-home (SAH) orders issued by state governors.

RESULTS

Our results show that states with the highest POQ in COVID-19 prevention were also states that had the quickest response from the governors to order their constituents to stay at home; the correlation between average preventive measures and length of time before an SAH order was placed was −0.47 (Table 1). These states were also inversely related to voting for a Republican presidential nominee in the 2016 election (R = −0.75). These findings indicate that by-state Republican voting was strongly correlated with longer delays in governor issuance of SAH orders. Further, the statewide voting percentage for a Republican presidential nominee in the 2016 election was inversely associated with POQ in any preventive measures, however, was positively associated with searches for hydroxychloroquine (R = 0.27) or azithromycin (R = 0.49) and was associated with longer delays in SAH orders (R = 0.48). Statewide average search interest in preventive measures is represented in Figure 1.

TABLE 1 Correlations of Preventive Measures Associated With COVID-19, Delay in Issuance of Stay-at-Home Orders, and Other Variables of Interest

^a Average interest in preventive measures (hand sanitizing, Handwashing, COVID-19 testing, and social distancing).

^b Days since March 1, 2020, stay-at-home order was issued.

^c Limited gatherings were rated based on level of restriction: bans on all gatherings = 0; 10 or more persons = 1; 25 or more = 25; 50 or more = 3.

^d Republican voting (%) from the 2016 presidential election results.

FIGURE 1 Average COVID-19 Prevention Search Interest