Scott A. Rivkees- Brown University School of Public Health, Providence, RI, United States
The first cases of COVID-19 in Florida were diagnosed on March 1, 2020. Three years later, more than 7.3 million people have had COVID-19 in Florida, and more than 93,000 individuals have died from this illness. When considering the impact of COVID-19 on Florida, several key factors need to be considered, including that Florida was one of the most medically vulnerable states due to a substantial proportion of older individuals and those with underlying medical conditions. Florida also has a centralized Department of Health and Division of Emergency Management structure that facilitated response activities. Looking at the impact of COVID-19 on Florida, two distinct phases need to be considered: the pre-Delta variant phase from March 2020 to July 2021 and the Delta variant and beyond phase that began July 2021 and still continues. During the 16-month first phase, about 38,000 people died. Yet, 24,000 people died during the 5-months of the Delta variant wave from July to November 2021. During the Omicron waves that followed Delta, an additional 31,000 people died. Florida thus went from ranking 26th in death per capita in the United States at the end of the first phase to 10th a few months into the Delta wave and now ranks 8th. Why did these phases differ so dramatically in terms of mortality? During the first phase of the pandemic, adherence to established nonpharmacological and older adult protection measures was recommended. When COVID-19 vaccines became available in December 2020, there was an aggressive campaign to promote COVID-19 vaccination, and public acceptance was high. The second phase followed political opposition to CDC and public health expert guidelines, the rise of anti-vaccine sentiment and misinformation, and falling vaccination rates. These factors contributed to considerable population vulnerability to severe disease when the Delta variant hit. As the former State Surgeon General and Secretary of Health of Florida from June 2019 to September 2021, this report provides perspective on the shifting impact and response to COVID-19 in Florida, which is the third most populous state in the United States. This perspective shows the clear consequences of shifting from standard public health practices and vaccine promotion to attacks on public health and vaccines.
Introduction
COVID-19 killed more than 1,100,000 people in the United States (1) and more than 93,000 people in Florida (2). More than 107 million people in the US and more than 7.5 million people in Florida have been documented to have COVID-19 infections, with the actual number of cases being far greater (2, 3).
In Florida, a Public Health Emergency (4) due to COVID-19 was issued on March 1, 2020 (5) and continued for 474 days (6). In response to COVID-19, there was a massive multiagency response in which Florida response agencies were allocated 8 billion dollars (7). The Florida Department of Health (DOH) and the Florida Division of Emergency Management (DEM) played leading roles during the response.
During the pandemic, states differed in population vulnerabilities, mitigation measures used, COVID-19 vaccination rates, and political approaches to the pandemic (8, 9). As such, state-to-state comparisons have attempted to relate COVID-19 outcomes to policies and actions (10–12). These analyses are complex, as mitigation strategies and implementation varied within states, and political strategies for COVID-19 control changed over time. Data from different pandemic phases are also grouped together in many studies, blending periods of low and high impact and masking the effects of changing policies and viral variants (8, 9, 11). In some studies, death rates have also been age-adjusted to facilitate comparison among different states; with this type of analysis, death rates seem lower in some states and higher in others than death per capita data (8, 9).
To assess COVID-19 impact, numbers of cases, hospitalizations, and deaths were collected and reported directly either by states, laboratories, hospital and nursing homes to the Centers for Disease Control and Prevention (CDC) or the Center for Medicare and Medicaid Services (CMS) during most of the Public Health Emergency (13). But with the advent of home testing, the varied expiration of state public health emergencies and reporting requirements, case and hospitalization data are often incomplete over the second half of the pandemic (12). Death data on the other hand, are still collected by the National Center for Health Statistics (14), and absolute numbers of deaths and death per capita data have been available since the start of the pandemic, making deaths per capita a practical comparator (13).
Florida is the third most populous state, with geographic and population diversity (15). Florida also had a changing political response over the pandemic (Table 1; Figure 1). Florida thus provides a special opportunity for assessing changes in policy, response, and COVID-19 variants within the same state.
Table 1. Chronology of key events during the COVID-19 pandemic in Florida.
Figure 1. Key events in COVID-19 pandemic in Florida.
In Florida, the pandemic can be split into two major phases: the pre-Delta variant phase from March 2020 to July 2021 and the Delta variant and beyond the stage that began July 2021 (Figure 2). During the first phase of the pandemic, the White Coronavirus Task Force and CDC recommendations were followed by the state, including physical distancing, crowd avoidance, vulnerable population protection, and face mask use (76). During this phase, the state locked down in April 2020, and state reopening began in early May 2020. In August 2020, public K-12 schools and universities opened for face-to-face activities. When it became available, an aggressive campaign to promote COVID-19 vaccination, especially in those who were older than 65 years (77). Reflecting the impact of these public health and vaccination measures, including 9 months before the COVID-19 vaccine became available, Florida ranked 20th and 26th among states in cases and deaths of COVID-19 per capita on June 30, 2021, before the Delta variant phase, respectively (78).
Figure 2. Deaths and Cases per 100,000 in Florida and United States over time. The period of the Delta and Omicron waves are shown.
The second phase of COVID-19 in Florida followed rising political opposition to COVID-19 mitigation measures and vaccines that began in early 2021, resulting in substantial population vulnerability to COVID-19. The 5 months of the Delta variant wave from July through November 2021, took a brutal toll on Floridians. Almost two-thirds as many people died during this period as over the 16 months before, as Florida had one of the highest actual and per capita death rates in the country during this time. By the end of the Delta variant wave, Florida rose to 10th in cases and deaths per capita. Reflecting the fact that Florida COVID-19 death rates have continued in excess of the rest of the United States, Florida now ranks 8th in death per capita (3).
Examining the different phases of COVID-19 in Florida, there are many lessons to be learned. The focus of this report is to provide insights into the shifting impact of COVID-19 in Florida by detailing important events in the pandemic, the unique vulnerabilities of Florida, the state pandemic response structure and strategies, and the changes in the response to the pandemic by Governor DeSantis.
Early events in the pandemic in Florida
Our first alert to COVID-19 was a message from the US Centers for Disease Control and Prevention (CDC) on January 8, 2020 (79), describing an outbreak of severe pneumonia of unknown cause in Wuhan, China. On January 17, 2020, the first public CDC briefing was held about COVID-19 (16). The first reported case of COVID-19 in the US was on January 20, 2020 (80).
In January 2020, DOH was dealing with a severe outbreak of hepatitis A and had an incident command team (IMT) that was active and redirected to prepare for COVID-19 (81). The DOH Division of Emergency Preparedness and Community Support team, which responds to disasters, was mobilized in mid-January for COVID-19. We also began engagement with the federal agency for Administration for Strategic Preparedness and Response (ASPR) with in-person meetings starting the third week of January (82).
On January 31, 2020, the federal government issued a travel advisory for individuals coming from China (18). Individuals arriving from China must isolate for 14 days and monitor symptoms. DOH was provided information about individuals arriving in Florida from China, and DOH staff contacted these individuals to begin at-home symptom monitoring. Of more than a 1000 individuals who came to Florida from China and were monitored, very few showed symptoms or tested positive for COVID-19.
On February 15, 2020, Vice President Pence, a White House Coronavirus Task Force member, visited Florida and held a press conference where the state of pandemic preparedness was discussed (83).
On February 28, 2020, the first day the CDC allowed state laboratories to use their internally developed COVID-19 test kit, we identified two individuals testing positive for COVID-19 (84). One was a woman who recently returned from northern Italy, a COVID-19 hotspot. The other was a man from Manatee County who had not traveled out of Florida but had recently visited the Florida Keys, where he was presumably exposed to a visitor with COVID-19.
The first deaths from COVID-19 in Florida occurred on March 7, 2020, in two older individuals who contracted COVID-19 during international travel (21).
Over the first half of March 2020, DOH contact tracing teams identified the source of exposure for all individuals who tested positive for COVID-19. Over the second half of the month, DOH could no longer find the potential sources of infection. Following CDC guidelines (85), we declared that there was community spread of COVID-19 in Florida.
In March 2020, national concern was that hospitals could be overwhelmed with COVID-19 patients. The United States Surgeon General recommended that hospitals limit elective procedures (86). On March 20, 2020, an executive order was issued in Florida limiting elective surgical procedures (87).
Ohio was the first state to close schools due to the COVID-19 pandemic on March 12, 2020 (88). The next day, the Florida Department of Education announced that Florida K-12 schools would close on March 16 (89). Florida state universities ceased face-to-face education in mid-March 2020 (90).
On March 16, 2020, the White House COVID-19 task force announced the “15 days to slow the spread” program (25). In mid-March 2020, counties and states issued stay-at-home or safer-at-home directives. South Florida counties issued orders limiting activities on March 17, 2020 (91). On April 1, 2020, the Governor issued Florida’s Safer-at-Home order (29), which remained in effect until phased reopening the following month.
The “Safe, Smart, Step-by-Step Plan for Florida’s Recovery” was the state’s reopening plan and was released on April 29, 2020 (32). On May 4, 2020, 64 of the 67 counties began the three-phase reopening plan (33). The three counties that did not initially reopen, Miami-Dade, Broward, and Palm Beach, accounted for more than 70% of the state’s cases at the time. These remaining counties began phased reopening 3 weeks later (92).
In August 2020, K-12 schools and the state university system reopened for face-to-face education as cases of COVID-19 increased during the summer (93).
COVID-19 vaccine first arrived in Florida December 14, 2020 (94), facilitating the shift from mitigation measures to vaccination as a primary strategy for COVID-19 disease control.
State of Florida vulnerabilities
By the end of January 2020, data from China showed that COVID-19 was especially deadly for older individuals (95). As cases in the US climbed, CDC data also showed that the risk of dying from COVID-19 rose progressively in people older than 65 years (96). Individuals with underlying medical conditions, including respiratory illness, immunocompromised states, and obesity, were especially vulnerable to COVID-19 as well (97).
In Florida, more than 21% of the population is 65 years and older, making it second to Maine in older people per capita (98). Out of nearly 22 million people in the state, more than 4.5 million are 65 or older. Based on the numbers of those with underlying medical conditions, an additional 2 million individuals younger than 65 were projected to be especially vulnerable to COVID-19 (99).
The CDC created a COVID-19 vulnerability index that accounted for population age and risk factors by meshing these risk factors together (100). By this metric, Florida was one of the most vulnerable states for COVID-19 severe illness and death, as well.
Complicating the risk for the state, in 2020, there were over 4,000 licensed nursing homes and assisted living facilities with 150,000 residents (101). Showing how deadly the virus could be within these facilities, at the end of February 2020, the first outbreak of COVID-19 in a nursing home in the US in Kirkland, Washington, resulted in many deaths (102). Soon after, deadly outbreaks of COVID-19 were reported in nursing homes in New York (103) and New Jersey (104).
Centralized response structure in Florida
Health departments nationwide have a centralized, decentralized, or hybrid organizational structure (105). A significant advantage of the Florida response was a centralized structure, with the DOH pivotal in directing statewide policy and activities at the county level. Florida has 67 counties, each with a county health department led by a county health officer (106). There are more than 12,000 employees of the DOH, including approximately 3,000 individuals working in Tallahassee, the state capital city.
DEM also has a centralized structure, interacting with county directors of emergency management. Because Florida has responded to many natural disasters and storms over many decades, the DEM is nationally renowned for its ability to respond to state emergencies.
DEM plays a significant role in providing logistical support during times of emergency. During the pandemic, DEM launched, orchestrated, and administered mass testing sites, mass vaccination sites, field hospitals, development of COVID-19-only nursing homes, movement of relief supplies around the state, and monoclonal antibody infusion sites. Former Florida House member Jared Moskowitz, now in the US Congress, was the DEM Director for most of the COVID-19 pandemic until April 2021, when DEM Deputy Director Kevin Guthrie succeeded him (107).
During the pandemic, the Agency for Health Care Administration (ACHA) monitored hospital responses and data collection and had authority over nursing homes. Over the first half of the pandemic, Sec. Mary Mayhew directed the agency (108).
During states of emergency, such as in hurricanes, operations are managed in the Emergency Operations Center (EOC) in Tallahassee. This command center is a hub for state agencies, emergency service function (ESF) teams, and federal partners, facilitating a coordinated state multiagency and federal response. To prevent COVID-19 outbreaks in the EOC that could jeopardize the response, symptom and COVID-19 contact screening were required upon entry, along with facemasks and twice-weekly COVID-19 testing.
The Florida STEPS plan
The primary plan that guided the DOH response to COVID-19 was implemented in January 2020. This was labeled the Florida STEPS plan (1): Social distancing (2), Testing and contact tracing (3), Older adult and medically vulnerable population protection (4), Preparing hospitals for a patient surge and health care worker protection, and (5) Stopping the introduction of COVID-19 into the state (17). Implementation of these components involved interactions with county departments of health, other state agencies, and community partners. These recommendations were based upon guidelines issued by the White House Coronavirus Task Force, the CDC, the Food and Drug Administration (FDA), and CMS. Florida instituted many of these protective COVID-19 control measures before Democratic-lead states and kept them longer than most other Republican-lead states (8, 109).
The DOH emphasized social distancing and nonpharmaceutical interventions throughout the pandemic. On March 1, 2020, the declared Public Health Emergency highlighted the importance of mitigation measures, including physical distancing, symptom monitoring, and facemasks. The DOH and DEM distributed millions of facemasks throughout the state as part of the response. Public information campaigns, including the “One Florida-One Goal” campaign was launched in the summer of 2020 to encourage mitigation strategy adherence (37). Separate public health advisories were issued From March 25 through July 21, 2020, emphasizing these measures (34, 36, 110). Beginning in April 2020, the DOH had regular calls with the Florida Chamber of Commerce to discuss mitigation measures and the importance of indoor ventilation.
Testing and contact tracing were activities the DOH planned before the first case in the state. DOH laboratories prepared for molecular-based COVID-19 testing at the end of January 2020. When the CDC test kit was approved, testing at DOH state laboratories began on February 28, 2020.
When the first FDA emergency use approved (EUA) commercially available molecular COVID-19 test kit became available (111), the state purchased enough kits to perform more than 650,000 tests. This exceeded the number of all test kits purchased by laboratories in the rest of the United States. Faced with shortages of reagents and supplies to run these and other COVID-19 tests, DOH established a clearinghouse whereby reagents used for university research purposes were redistributed to laboratories where COVID-19 testing was performed.
During March 2020, we expanded public reporting of COVID-19 cases by developing a public dashboard in which county-level information was displayed (112). Personnel at county health departments performed contact tracing of individuals with or exposed to COVID-19. Beginning in February 2020, to provide additional epidemiological support, the DOH hired more than 600 students and faculty from public health schools in the state (113). By June 2020, more than 4,400 people were involved in COVID-19 contact tracing (114).
Older adult protection and the protection of those with underlying medical conditions were a significant focus for the state. When one looks at comparative mortality in Florida versus other states over the first year and a half of the pandemic (first phase), despite a substantial at-risk population, Florida fared better than many other large states due to these efforts (115).
In February and March 2020, DOH and ACHA teams visited more than 4,000 nursing homes and assisted living facilities to provide education about COVID-19 infection control (116). On March 11, 2020, all visitation to these facilities was suspended. On March 20, 2020, Florida was one of the first states, if not the first, to recommend that all staff members wear face masks (117). DOH established a call center for facilities needing assistance, and joint DOH and AHCA strike teams visited facilities when there was a COVID-19 case (118). DEM and ACHA established COVID-19-only nursing homes (119) or COVID-19 isolation areas in nursing homes.
Preparing hospitals and healthcare systems for the pandemic began in mid-January 2020. Florida has more than 68,000 licensed hospital beds. Helping hospitals prepare for the pandemic, a series of weekly or twice weekly scheduled calls coordinated by the Florida Hospital Association involving DOH and ACHA started on February 3, 2020 (120).
To monitor hospital bed capacity, the ACHA activated the Emergency Status System (ESS) (121), by which hospitals electronically report information daily. Hospitalization, intensive care utilization, and ventilator accessibility were reported to the state and the Center for Medicare and Medicaid Services (CMS). After a drop in cases, the ESS system stopped collecting and publicly reporting data in the spring of 2021.
Stopping the introduction of COVID-19 into the state was part of the initial Florida pandemic control strategy. Following CDC travel advisory recommendations on March 9, 2020, the DOH advised people from countries and cruises with CDC level 2 and 3 COVID-19-related travel advisories to monitor their symptoms, avoid public places, and avoid being around people 65 years or with underlying medical conditions.
At large airports in the state, the DOH and the National Guard personnel screened passengers upon arrival and gave instructions for self-isolation (122). Roadblocks were set up along Florida highways at entry points to the state to identify those from areas of outbreaks, conduct health screenings, and require self-isolation (123). When Florida case counts rose in June 2020, these measures were discontinued as not viewed to be effective (124).
K-12 schools and universities
After the closure of schools nationally to in-person education in March 2020, the adverse impact of school closures became increasingly apparent. The American Academy of Pediatrics and other organizations thus advocated for the safe return to school of children for the start of the 2020 school year (125). Besides educational and social concerns, the impact on the workforce related to school closures was considerable. Parents or guardians could not return to work while their children were at home, coupled with a lack of access to daycare. This issue also factored in the push to reopen schools for in-person education.
On July 6, 2020, Commissioner of Education Richard Corcoran issued an order requiring all publicly funded schools in the state to offer in-person instruction 5 days per week (38). The federal government provided extensive funding to the state and local school districts to support COVID-19 control measures in schools via the Elementary and Secondary School Emergency Relief (ESSER) Fund (122), with Florida receiving more than $650 million initially. School districts had the statutory authority to determine their mitigation strategies. These protective strategies varied among counties and school districts; some schools gave parents the option of face-to-face or remote learning, while in some communities, only face-to-face learning was available (126).
In preparation for the return to school, the CDC developed guidelines for the return to the classroom. However, the release of these guidelines was delayed until September 15, 2020, after children returned to schools in Florida and many other states (42, 127). In advance of CDC guidance, DOH and the Florida Department of Education (DOE) implemented numerous practices to support the safe return to school (39). Testing capacity at state laboratories was augmented so there would be a 24-h turnaround of tests, procedures for screening students on arrival to school for COVID-19 symptoms were implemented, schools had contact tracing teams, individuals with COVID-19 or exposure were identified and excluded from school per CDC guidelines (128), improved ventilation of schools took place, and school attendance was monitored. DOH developed an internal dashboard and report to monitor all schools in the state for cases of COVID-19, which were reviewed daily (129). When exposures resulted in a classroom being quarantined or other potential significant exposure events, data and response actions were reviewed centrally at the DOH.
When students returned to school in August 2020, community levels of COVID-19 were high in most of the state and in the range the CDC recommended against face-to-face education (130). The return to in-person instruction went well, as among 6,400 public K-12 schools in the state, 11% had outbreaks that could be traced to school or school-related activities (131).
Under the guidance of the Board of Governors, state universities resumed face-to-face education in August 2020 (132). Federal and state funding was also available to support these activities. COVID-19 control practices involved using facemasks, improving ventilation, COVID-19 testing, university-based contact tracing teams, and residential arrangements for individuals with COVID-19 or directly exposed to those with COVID-19 to isolate them. As in the K-12 setting, few outbreaks could be linked to the academic setting. Instead, outbreaks were most commonly related to non-classroom social activities.
The academic year was modified so students would not have traditional breaks when they would travel home and potentially reintroduce COVID-19 upon return (133). Thus, face-to-face education ended with the Thanksgiving holidays of 2020, and spring breaks were canceled for the 2021 school term (134).
The return to school in the summer of 2021 was more contentious than the previous year, as in July 2021, the Governor prohibited school districts from issuing mask mandates, and financial penalties were assessed against school officials from districts requiring mask use (134, 135). CDC guidance at this time recommended the use of face masks in schools (136).
As in the previous year, school testing for COVID-19, contact tracing, outbreak monitoring, and a focus on improving school ventilation continued. In addition, millions of home test kits were made available to schools for distribution. In contrast to the CDC policy of 10 days, the quarantine period was shortened to 7 days. Despite prohibitions against school mask mandates, the DOH return to school rule required that parents opt out of mask-wearing (137). In September 2021, mandatory quarantining of exposed students was stopped (138).
Large events were avoided at the university level during the 2020–2021 school year, but large gatherings at sporting events took place during the 2021–2022 school year. With the return of full sports stadiums in the fall of 2021 during the Delta wave, few outbreaks were associated with these outdoor activities.
COVID-19 vaccination
The first COVID-19 vaccines to be granted FDA emergency use authorization (EUA) status were the Pfizer/Biontech vaccine on December 12, 2020 (45), followed by the Moderna vaccine on December 18, 2020 (139). The Johnson and Johnson vaccine received EUA on February 27, 2021 (140). The COVID-19 vaccine was in limited supply for adults until April 2021. Thus, vaccine allocation was prioritized by the state.
On December 3, 2020, The CDC Advisory Committee on Immunization Practices (ACIP) and the CDC Director initially recommended vaccinating those 75 years and older, essential workers, people in nursing homes, and healthcare providers (46). Considering the considerable number of people in the state who were 65 years and older, the state deviated from ACIP recommendations (141), first allocating vaccines to those 65 years and above, those certified by their physician as having a serious underlying medical condition, those in nursing homes, and healthcare workers with direct patient exposure.
COVID-19 vaccine arrived in Florida on December 14, 2020 (94). Vaccination efforts for those 65 and older were initially challenged by demand far greater than supply, outdated patient registration systems, and long lines at vaccination sites (142). Plans were implemented to limit vaccine tourism in favor of vaccination of Florida residents (143). Retail pharmacy chains helped vaccinate nursing home residents, and DOH implemented COVID-19 vaccination programs for home-bound senior citizens (144). Showing the effectiveness of this approach, by early 2021, Florida had one of the highest vaccination rates for those 65 and older individuals in the country (77).
Focusing on health equity issues to reach minority communities, DOH and DEM worked with faith-based organizations (145), with faith-based vaccination events beginning in December 2020 (146). The state established mass vaccination sites in many areas. To reach groups with high social vulnerability, FEMA initiated several vaccination sites in the state (147).
Rates of vaccination in Florida rose steadily through mid-April 2021 when those 16 years and older were approved for the vaccine. Afterward, vaccination rates sharply declined (143) following a rise in anti-vaccine sentiment and a lack of promotion by the Governor.
Before the end of the spring term for college and university students in 2021, mass vaccination events were held at sites for higher education throughout the state (148), many of which took place at sports stadiums to accommodate a substantial number of students. On May 10, 2021, the COVID-19 vaccine became available for those 12 years and older (149), and DOH partnered with pediatric providers for vaccination events (150).
On November 2, 2021, COVID-19 vaccine became available for those 5 years and older (151). Unlike CDC recommendations, the new State Surgeon General, Dr. Ladapo, stated that healthy children should not receive COVID-19 vaccines (152). On June 18, 2022, the COVID-19 vaccine was authorized for those 6 months and older (153). Florida was the only state not to pre-order vaccines for this age group.
On October 7, 2022, Dr. Ladapo advised that young men should not be vaccinated against COVID-19 due to the risk of myocarditis (71) On September 13, 2023, Dr. Ladapo recommended that individuals younger than 65 should not receive the updated COVID-19 booster (74). On January 3, 2024, Dr. Ladapo recommended that all individuals avoid COVID-19 mRNA vaccines (75). Each of these recommendations are in stark contrast to current CDC guidelines that state that all those in eligible age groups should receive updated COVID-19 shots (154).
The delta-variant wave
Over the pandemic, there have been five waves of different variants (155). Of these, the Delta variant was the deadliest (156). This variant first appeared in India in the winter of 2021 (157) and reached the US in the spring of 2021 (158).
Individuals vaccinated against COVID-19 were protected against the severe effects of the Delta variant (159). Thus, unvaccinated or incompletely vaccinated individuals were especially susceptible to this variant. As observed in other states, COVID-19 vaccination rates in Florida varied with political affiliation (160).
The Delta wave began in Florida in July 2021, severely affecting Jacksonville in Duval County, which had lower vaccination rates than many other large cities in Florida (161). Hospital leadership reported that 95% of individuals hospitalized and dying from the Delta variant were unvaccinated. Duval County hospital capacity was so overwhelmed that a hospital executive requested the USS Comfort hospital ship to provide local support. In other areas of the state, hospitalization rates and the need for oxygen were so severe that oxygen use for water treatment plants was curtailed (157), and some hospitals only had a few days’ supply available during the Delta wave (162).
In response, in August 2021, more than 25 sites were established by DOH and DEM so that Regeneron monoclonal antibody infusions could be given to individuals with COVID-19 to lower the risk of progression to severe disease (163). Based upon known hospitalization rates with COVID-19 and the age of individuals becoming infected, approximately 1,000 infusions are projected to prevent 50 hospitalizations. More than 130,000 individuals received monoclonal antibody treatment at an average cost of $2,100 per dose, potentially preventing 6,000 hospitalizations (164).
Although it was suggested that many individuals receiving monoclonal antibodies had breakthrough cases (165), DOH did not systematically collect health information on individuals receiving infusions. Reports from hospitals indicated that more than 95% of individuals with severe COVID-19 had not been vaccinated. During the later Omicron wave in the winter of 2022, Florida continued to promote the Regeneron monoclonal strategy (166), even when the Omicron variant was not susceptible to the Regeneron monoclonal antibody, and the FDA EUA was revoked when the Omicron variant accounted for 99% of cases (167).
Over the 5 months of the Delta wave, more than 24,000 individuals died from COVID-19 in Florida compared to 38,000 individuals over the preceding 16 months. During the Delta wave peak, Florida had one of the highest COVID-19 death rates in the country (3, 168, 169). Reflecting this impact, Florida went from 26th in death per capita due to COVID-19 to 10th (3). If one examines COVID-19 or excess mortality deaths per capita over the Delta and beyond period alone, Florida ranks even worse (168, 169). It has been calculated if there had been better COVID-19 vaccine coverage through August 31, 2021, more than 16,000 deaths in Florida during the Delta wave would have been prevented (170).
Changes in the governor’s response to COVID-19 during the pandemic
Before the first case of COVID-19 in the state, the messages delivered by Governor DeSantis focused on transparency in COVID-19 reporting and following guidelines released by the White House Coronavirus Taskforce and the CDC, including non-pharmaceutical mitigation measures. The early stages of the pandemic response action in Florida were similar to that seen in most of the country (171).
Before the first case in the state, DOH did not release information about the number of individuals tested or aggregate test results, believing that such release of information was at variance with state statute 381 (172). On February 28, 2020 (173), however, the Governor directed DOH to release all test results to promote transparency.
With the support of the Governor, separate public health advisories were issued by me, beginning in March 2020, that emphasized social distancing and mask use (110). At this time, DOH developed a COVID-19 public-facing dashboard showing cases, hospitalizations, positivity rates, and deaths per county (112).
On March 21, 2020, President Trump promoted hydroxychloroquine (168), which the FDA was pressured to grant EUA for early in the pandemic. On April 7, 2020, Governor DeSantis announced that Florida purchased 1 million doses of hydroxychloroquine from manufacturer Teva (174). The next day he held a press conference featuring a patient ill with COVID-19 treated with hydroxychloroquine to promote its use (175). Recent data show that the use of hydroxychloroquine during COVID-19 has been linked to about 17,000 deaths (176).
In mid-March, several states and Florida counties began issuing activity restriction orders to control the outbreak (177). During February and March 2020, images of college students celebrating spring breaks in Florida were broadcast as cases began to rise, triggering criticism by the media of state tourism remaining open (178). Being one of the last states to do so, on April 1, 2020, the Florida “Safer at Home” order was issued statewide by the Governor (179).
As President Trump shunned mask use, anti-face mask sentiment rose nationally (180). On April 13, 2020, the Governor’s Press Secretary removed me from a press conference after I stated mitigation measures would be needed until the COVID-19 vaccine became available.
On April 28, 2020, Governor DeSantis met with President Trump at the White House, focusing on how well Florida did during the early part of the response (31). Governor DeSantis stated, “Everyone in the media was saying Florida was going to be like New York or Italy, and that has not happened.”
The plan to reopen Florida had input from many sectors, including business, education, healthcare, and tourism. On May 4, 2020, 64 of the 67 counties in the state went to Phase 1 of reopening. As parts of the state began to reopen, DOH could trace several COVID-19 outbreaks to bars that were not adhering to limited-capacity reopening standards. On June 26, 2020, the Director of the Department of Business and Professional Relations (DBPR) ordered the bars to close again (181).
Over the summer of 2020, as COVID-19 cases began to rise, the “One Florida-One Goal” publicity campaign was launched, emphasizing the importance of mitigation measures, including facemasks (37). This campaign coincided with the second wave of COVID-19 infections that summer. Before the 4th of July holiday, the Governor emphasized wearing a mask and avoiding closed spaces and crowded places.
On July 6, 2020, the Commissioner of Education required that all schools open for in-person education (182). In some communities, there was pushback against this policy, followed by threats that the state would withhold school district funds for noncompliance (183).
In the summer of 2020, as part of the national discussion to downplay the effects of the virus, there was an attempt to show that deaths attributed to COVID-19 were not caused by the virus (184). There were incorrect claims that accident-related cases were being attributed to COVID-19 (185). A reporter was given access by the Governor’s office to the death certificates of individuals who died from COVID-19. The reporter claimed that many COVID-19-related deaths were falsely classified as such (186).
In mid-August, DOH was asked by the Governor’s office to remove the mention of masks and related infographics from the website.
A newly appointed member of the President Trump White House Coronavirus Task force, Dr. Scott Atlas, came to Florida for press conferences on August 31, 2020, to support reopening schools. He emphasized that the best way to protect older adults was to have younger individuals get COVID-19 and develop herd immunity (41).
On September 24, 2020, the Governor hosted a round table discussion with individuals who originated the Great Barrington Declaration (43). These individuals focused on the low risk that COVID-19 posed to school-age children and college students, commenting on the harm associated with in-person school closures. They advocated that the best way to protect older and at-risk individuals from COVID-19 was to have younger individuals get COVID-19, resulting in population immunity, the “let it rip” philosophy, and minimizing the effectiveness of masks (187). On September 25, 2020, local municipalities were prohibited from issuing fines to individuals not wearing masks (188).
Similar to calls issued by President Trump to reduce testing for COVID-19 (185), so there would be fewer cases diagnosed, Governor DeSantis made similar requests to DEM (189). Testing was not reduced by either DOH or DEM.
The Governor was initially enthusiastic about COVID-19 vaccines (190). The Governor signed the receipt of the shipment for the first COVID-19 vaccines to arrive in Florida (94). From December 2020 through March 2021, the Governor had numerous press conferences and public events promoting vaccination.
In April 2021, President Biden became more active in advocating for COVID-19 vaccination (191), setting a 70% national vaccination rate goal (192) by the 4th of July, 2021. After vaccine promotion comments by President Biden, Governor DeSantis, and other Republican Governors reduced or stopped promoting COVID-19 vaccination (193). There was also growing sentiment among conservatives that it was better to develop immunity to COVID-19 from infection than from vaccination (194). Whereas, COVID-19 infections can confer immunity to the virus, the degree of protection is more variable than immunity conferred following vaccination, and the risk of severe disease from natural infection outweighs the risk of vaccination (195, 196).
With the significant impact of the Delta-variant wave in July 2021, Governor DeSantis briefly resumed pro-vaccine comments (197). On September 13, 2021, he failed to correct false information from a co-speaker at a press conference stating that vaccines alter genetic material (198).
In June 2021, the DOH was instructed to replace daily COVID-19 reports with weekly reports that were initially released early Friday afternoon, and then later after 5 PM (199). This shift was to minimize COVID-19 being in the public eye.
The collapse of the condominium tower in Surfside (200) also impacted the COVID-19 response. Out of respect for this tragedy, the DOH was instructed by the to withhold all COVID-19-related messaging. This pause lasted approximately 1 month as the Delta variant wave was appearing. This pause delayed the release of a DOH-sponsored vaccine promotion campaign that had been proposed in March 2021 and was finally released in the summer of 2021 (201).
When the Delta virus hit (187), the focus was on Regeneron monoclonal antibody infusions (202). The Governor attributed the impact of the summer Delta surge to seasonality (190), not human factors.
The ESS, which provided a public snapshot of COVID-19 hospitalizations, was operational over the first half of the pandemic until cases fell in the winter of 2021. During the Delta wave, hospital executives requested that it be reactivated, but this request was denied.
In the summer of 2020, local school districts and counties determined COVID-19 policies. On July 30, 2021, the Governor overrode local guidelines and prohibited mask mandates in K-12 schools (135). In August 2021, the Governor began focusing on how respiratory syncytial virus (RSV), was more of a threat than COVID-19 to children (203).
On March 18, 2021, the Governor hosted a round table discussion with originators of the Great Barrington Declaration, in which the use of face masks by children was discredited. The next day, YouTube removed the video of the press conference saying that it contradicted expert opinion (204).
On April 2, 2021, the Governor prohibited businesses from having vaccine passports for business entry or COVID-19 vaccine requirements (205). DOH was directed to investigate circumstances where companies inquired about vaccine status for entry. DOH was charged with investigating these violations, with a penalty of $5,000 per event per person (206).
On July 13, 2021, Norwegian Cruise Lines, which had a vaccine requirement for passengers, sued me as representative of the state of Florida over this issue (207). A federal judge ruled that the cruise industry was entitled to require COVID-19 vaccination for passengers and staff (208).
On July 13, 2021, As COVID-19 cases in Florida reached the highest in the nation, the Governor DeSantis campaign team rolled out “Do not Fauci My Florida” merchandize (58).
With the rise of COVID-19 cases during the Delta variant surge in Florida, on August 3, 2021, President Biden admonished Governor DeSantis to “get out of the way,” of the state COVID-19 response (209). This episode triggered pushback by Governor DeSantis against President Biden’s COVID-19 policies (210).
On September 4, 2021, President Biden called for vaccine mandates for businesses with 100 employees or more and health care workers. On October 28, 2021, Governor DeSantis announced a lawsuit against the vaccine mandates (63).
On November 18, 2021, Employers were prohibited from requiring employees to be vaccinated against COVID-19 (135). When the Supreme Court upheld the Biden administration’s requirement that healthcare workers be vaccinated on January 14, 2022, Governor DeSantis stated that Florida would not enforce the ruling (211).
At a press conference on March 2, 2022, the Governor chided high school students for wearing masks, calling their use “political theater.” (212).
On December 13, 2022, the Governor empowered a grand jury to investigate vaccine manufacturers for COVID-19 (198). A partisan Public Health Integrity Committee, constituted by supporters of the Great Barrington Declaration, was also commissioned to assess the response to the pandemic (72, 73).
On May 11, 2023, the legislation banning COVID-19-related mandates was enacted (213).
On November 2, 2021, COVID-19 vaccine became available for those 5 years and older (151). In contrast to CDC recommendations, the new State Surgeon General, Dr. Ladapo, stated that healthy children should not receive COVID-19 vaccines (152).
On June 18, 2022, COVID-19 vaccine was authorized for those 6 months of age and older (153). Florida was the only state not to pre-order vaccines for this age group.
On October 7, 2022, Dr. Ladapo advised that young men should not be vaccinated against COVID-19 due to the risk of myocarditis (71).
On September 13, 2023, Dr. Ladapo and Governor DeSantis recommended that individuals younger than 65 should not receive the updated COVID-19 booster (74).
On November 1, 2023, after announcing that individuals younger than 65 should not receive the updated COVID-19 booster (214), Dr. Ladapo campaigned with Gov. DeSantis in New Hampshire to promote medical freedom (215).
.On January 3, 2024, Dr. Ladapo recommended that all individuals avoid COVID-19 mRNA vaccines (75).
Synopsis
As the COVID-19 death toll passes 93,000 in Florida, it is essential to assess what worked well in the response and what did not. The answer to these questions lies in examining the different strategies and actions over the first 16 months of the pandemic, during which Florida had one of the lower mortality rates in the US despite being one of the most medically vulnerable states, to being one of the most severely impacted states during the Delta variant wave and beyond.
Over the first phase of the pandemic, there was a strong focus on mitigation and vaccination measures, with emphasis directed toward protecting older individuals who were most vulnerable to the virus. We also observed that before the availability of COVID-19 vaccines, public health measures facilitated the successful phased re-opening of communities and businesses after the April 2020 lockdown. We also observed that public health measures supported the successful reopening of K-12 schools and institutions of higher education at a time the country was divided on the school reopening issue, and many schools did not open nationally.
Over the first 6 months after vaccines first became available, there was considerable enthusiasm for COVID-19 vaccination, especially among older people, contributing to the low state mortality rates. Yet, with the rise of COVID-19 misinformation, anti-vaccine sentiment, and waning political support for COVID-19 vaccines by the Governor, vaccination rates fell, resulting in population vulnerability. Thus, when the severe Delta variant wave hit Florida in the summer of 2021, cases of severe COVID-19 spiked in younger and unvaccinated individuals. Continuing this trend, death rates in Florida have been among the highest in the country during recent waves of Omicron variants.
There are lessons to be learned not just for Florida but for the country in examining the response to and the impact of COVID-19 on the state. Rather than the partisan Public Health Integrity Committee, commissioned by Governor DeSantis to assess the response to the pandemic (73), the state would be much better served by the bipartisan panel with scientific expertise. Such was the model implemented last year, by the Republican Governor of Indiana, who convened a bipartisan commission with respected public health experts to assess health issues in the state, including COVID-19 and the public health response (216). Alternatively, medical schools and schools of public health in Florida could collectively perform the type of independent, rigorous analysis they are capable of or at least begin to advocate for such.
For now, we can see the clear benefit of COVID-19 mitigation and vaccination strategies over the first phase of the pandemic in Florida. We can also see the consequences of abandoning core mitigation strategies and stopping the promotion of protective vaccines, looking at how Floridia has been affected by severe COVID-19 ever since.
Author contributions
SR: Conceptualization, Writing – original draft, Writing – review & editing.
Funding
The author(s) declare that no financial support was received for the research, authorship, and/or publication of this article.
Conflict of interest
The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Publisher’s note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
References
1. Centers for Disease Control and Prevention. COVID Data Tracker. (2023). Available at: https://covid.cdc.gov/covid-data-tracker/#datatracker-home.
2. Centers for Disease Control and Prevention. Weekly United States COVID-19 Cases and Deaths by State – ARCHIVED. (2023). Available at: https://data.cdc.gov/Case-Surveillance/Weekly-United-States-COVID-19-Cases-and-Deaths-by-/pwn4-m3yp.
3. Worldometer. United States Coronavirus Cases. (2023). Available at: https://www.worldometers.info/coronavirus/country/us/.
4. Declaration of Public Health Emergency. (2020). Available at: https://floridahealthcovid19.gov/wp-content/uploads/2020/03/declaration-of-public-health-emergency-covid-19-3.1.20.pdf.
6. Braten, SR, Casanover, MH, and Marra, PS. End to Florida’s state of emergency declaration. (2021). Available at: https://rosenbaumpllc.com/end-to-floridas-state-of-emergency-declaration/.
7. Florida Department of Financial Services. Coronavirus Relief Fund. (2023). Available at: https://www.myfloridacfo.com/caresact/#:~:text=Coronavirus%20Relief%20Fund&text=Of%20this%20amount%2C%20the%20State,directly%20by%20the%20U.S.%20Treasury.
8. Bollyky, TJ, Castro, E, Aravkin, AY, Bhangdia, K, Dalos, J, Hulland, EN, et al. Assessing COVID-19 pandemic policies and behaviours and their economic and educational trade-offs across US states from Jan 1, 2020, to July 31, 2022: an observational analysis. Lancet. (2023) 401:1341–60. doi: 10.1016/S0140-6736(23)00461-0
9. Hamad, R, Lyman, KA, Lin, F, Modrow, MF, Ozluk, P, Azar, KMJ, et al. The U.S. COVID-19 county policy database: a novel resource to support pandemic-related research. BMC Public Health. (2022) 22:1882. doi: 10.1186/s12889-022-14132-6
10. Lurie, N, and Sharfstein, JM. State-to-state differences in US COVID-19 outcomes: searching for explanations. Lancet. (2023) 401:1314–5. doi: 10.1016/S0140-6736(23)00726-2
11. Radley, David C, Baumgartner, Jesse C, and Collins, Sara R. Scorecard on state health system performance: how did states do during the COVID-19 pandemic? (2022). Available at: https://www.commonwealthfund.org/publications/scorecard/2022/jun/2022-scorecard-state-health-system-performance.
12. Tam, KM, Walker, N, and Moreno, J. Influence of state reopening policies in COVID-19 mortality. Sci Rep. (2022) 12:1677. doi: 10.1038/s41598-022-05286-9
13. CDC. Where does our data come from? (2023). Available at: https://www.cdc.gov/surveillance/data-modernization/basics/where_does_our_data_come_from.html.
14. COVID-19 Death Data and Resources. (2023). Available at: https://www.cdc.gov/nchs/nvss/covid-19.htm.
15. America Counts Staff. Florida Was Third-Largest State in 2020 With Population of 21.5 Million. (2021). Available at: https://www.census.gov/library/stories/state-by-state/florida-population-change-between-census-decade.html.
16. Centers for Disease Control and Prevention. Transcript of. Novel Coronavirus Response Telebriefing. (2019). Available at: https://www.cdc.gov/media/releases/2020/t0117-coronavirus-screening.html.
17. Rivkees, S, and Roberson, S. The Florida Department of Health STEPS public health approach: the COVID-19 response plan and outcomes through may 31, 2020. Public Health Rep. (2020) 135:560–4. doi: 10.1177/0033354920946785
18. White House Trump Administration. Proclamation on Suspension of Entry as Immigrants and Nonimmigrants of Persons who Pose a Risk of Transmitting. Novel Coronavirus. (2019). Available at: https://trumpwhitehouse.archives.gov/presidential-actions/proclamation-suspension-entry-immigrants-nonimmigrants-persons-pose-risk-transmitting-2019-novel-coronavirus/.
19. News 4 Jax. Duval County health department’s mobile unit offers COVID-19 testing at 2 locations. News 4 Jax (2020).
20. State of Florida Department of Health. Department of Health Announces Two Presumptive Positive COVID-19 Cases in Florida. (2020). Available at: https://www.floridahealth.gov/newsroom/2020/03/030120-two-presumptive-positive-covid19-cases.pr.html.
22. Schweers, J. Coronavirus: Florida Gov. DeSantis activates state's Emergency Operations Center after deaths. The Florida Times-Union (2020).
24. State of Florida Department of Education. Florida department of education provides recommendations for spring break. (2020). Available at: https://www.fldoe.org/newsroom/latest-news/florida-department-of-education-provides-recommendations-for-spring-break.stml.
25. White House Trump Administration. 15 days to slow the spread. (2020). Available at: https://trumpwhitehouse.archives.gov/articles/15-days-slow-spread/.
26. State of Florida Office of the Governor. Governor Ron DeSantis Issues an Executive Order Regarding Bars, Beaches and Restaurants. (2020). Available at: https://www.floridahealth.gov/newsroom/2020/03/031720-governor-ron-desantis-issues-executive-order-regarding-bars-beaches-restaurants.pr.html.
27. State of Florida Department of Health. Updated measures to ensure protection of public health in response to COVID-19. (2020). Available at: http://www.mcmh.us/wp-content/uploads/2020/07/public-health-advisory-7.20.2020.pdf.
30. Wallace, D. Florida's DeSantis orders 1 million doses of controversial anti-malaria drug before nearing coronavirus peak. Fox News (2020).
31. Wilkie, C, and Breuniner, K. Trump and Florida Gov. Ron DeSantis meet at White House as states start to reopen. CNBC (2020).
32. Plan for Florida’s Recovery. (2020). Available at: https://www.flgov.com/wp-content/uploads/covid19/Taskforce%20Report.pdf.
33. McLaughlin, E, Flores, R, Weisfeldt, S, and Morris, J. Florida will start to reopen, but for now Miami-Dade and two other counties won’t be included. CNN (2020).
34. Updated Public Health Advisory. (2020). Available at: https://floridahealthcovid19.gov/wp-content/uploads/2020/06/20200622-SOF-DOH-Public-Health-Advisory.pdf.
36. Centers for Disease Control and Prevention. Updated measures to ensure protection of public health in response to COVID-19. (2020).
37. Florida Office of the Governor. Governor Ron DeSantis announces one goal one Florida initiative to unite Floridians against COVID-19. (2020). Available at: https://www.flgov.com/2020/07/31/governor-ron-desantis-announces-one-goal-one-florida-initiative-to-unite-floridians-against-covid-19/#:~:text=%E2%80%93%20Today%2C%20Governor%20Ron%20DeSantis%20announced,challenge%2C%E2%80%9D%20said%20Governor%20DeSantis.
39. The State of Florida Issues COVID-19 Updates. (2020). Available at: https://www.floridahealth.gov/newsroom/2020/08/081420-1728-covid19.pr.html.
40. Fraser, J, Stucka, M, Bloch, E, Fradette, R, and Brugal, S. Florida schools reopened en masse, but a surge in coronavirus didn't follow, a USA TODAY analysis finds. USA Today (2020).
41. Sarkissian, A, and Atterbury, A. Atlas makes Florida swing, backing DeSantis on schools and sports. Politico (2020).
42. Centers for Disease Control and Prevention. CDC Releases Indicators for Dynamic School Decision-Making. (2020). Available at: https://www.cdc.gov/media/releases/2020/s0915-dynamic-school-decision-making.html.
43. DiMichele, A. Ron DeSantis and medical experts talk reopening at COVID-19 roundtable. Herald-Tribune (2020).
45. Howard, J. FDA issues emergency use authorization for Pfizer/BioNTech Covid-19 vaccine. CNN (2020).
46. Dooling, K, Marin, M, Wallace, M, McClung, N, Chamberland, M, Lee, GM, et al. The Advisory Committee on Immunization Practices' Updated Interim Recommendation for Allocation of COVID-19 Vaccine - United States, December 2020. MMWR Morb Mortal Wkly Rep. (2020) 69:1857–9. doi: 10.15585/mmwr.mm6949e1
47. Associated Press. ‘Historic’ moment in Florida as first COVID vaccines given. Associated Press (2020).
49. Florida Department of Heralth. Prioritization of Floridians for COVID-19 vaccinations given in Florida. (2021).
50. State of Florida Office of the Governor. Governor Ron DeSantis Signs Landmark Legislation to Ban Vaccine Passports and Stem Government Overreach. (2021). Available at: https://www.flgov.com/2021/05/03/governor-ron-desantis-signs-landmark-legislation-to-ban-vaccine-passports-and-stem-government-overreach/#:~:text=Additionally%2C%20the%20legislation%20codifies%20the,proof%20of%20COVID%2D19%20vaccination.
52. Gebhart, A. Biden and Obama added to Sunday TV special promoting COVID-19 vaccines. CNET (2021).
53. Florida Department of Health. State Surgeon General Issues Public Health Advisory Rescinding Previously Issued Advisories, Expanding Vaccine Eligibility, and Encouraging the Resumption of In-Person Government Operations and Services Statewide. (2021). Available at: https://www.floridahealth.gov/newsroom/2021/04/20210429-Public-Health-Advisory-filed-4.29.21.html (Accessed July 26, 2021).
54. Florida Will No Longer Release Daily. COVID-19 Numbers, Moves to Weekly Reports. NBC Miami (2021).
55. Sangal, A, Wagner, M, Macaya, M, Rocha, V, Alfonso, F, and Berlinger, J. Partial building collapse near Miami. CNN (2021).
56. Services USDoHaH. COVID-19 Vaccines. (2023). Available at: https://www.hhs.gov/coronavirus/covid-19-vaccines/index.html (Accessed July 26, 2023).
57. Pipitone, T. Florida Delta Wave Cases Plunge, Leaving Record Deaths in Its Wake. NBC Miami (2021).
58. Knowles, H. DeSantis sells ‘Don’t Fauci my Florida’ merch as new coronavirus cases near highest in nation. Washington Post, July 16, (2021). https://www.washingtonpost.com/politics/2021/07/13/desantis-fauci-florida/.
59. Governor DeSantis. Governor DeSantis Issues an Executive Order Ensuring Parents’ Freedom to Choose. (2021). Available at: https://www.flgov.com/2021/07/30/governor-desantis-issues-an-executive-order-ensuring-parents-freedom-to-choose/.
60. Dahm, D. DeSantis announces opening of monoclonal antibody treatment site in Bonita Springs. Click Orlando (2021).
61. Rankin, M. DeSantis encouraging people to learn about monoclonal antibody treatment for COVID-19. Tampa Bay (2021).
62. Sarkissian, A. How a doctor who questioned vaccine safety became DeSantis’ surgeon general pick. Politico (2021).
63. Governor Ron DeSantis. Announces Lawsuit Against Biden Administration’s Unconstitutional Vaccine Mandates. (2021). Available at: https://www.flgov.com/2021/10/28/governor-ron-desantis-announces-lawsuit-against-biden-administrations-unconstitutional-vaccine-mandates/.
64. State of Florida Office of the Governor. Governor Ron DeSantis Signs Legislation to Protect Florida Jobs. (2021). Available at: https://www.flgov.com/2021/11/18/governor-ron-desantis-signs-legislation-to-protect-florida-jobs/.
65. Hodgson, I, and O’Donnel, C. Florida sees signs of a COVID surge, but hospitals coping so far. Tampa Bay Times (2022).
66. Schweers, J. Florida won't be Biden's 'biomedical police,' DeSantis' office says after Supreme Court ruling. Tallahassee Democrat. (2022).
67. State of Florida Department of Health. Monoclonal Antibody Sites Statewide Will Be Closed After FDA Removes Treatment Authorization. (2022). Available at: https://www.floridahealth.gov/newsroom/2022/01/20220124-fda-removes-treatment-authorization.pr.html#:~:text=Unfortunately%2C%20as%20a%20result%20of,be%20closed%20until%20further%20notice.&text=https%3A%2F%2Ffloridahealthcovid19,the%20absence%20of%20clinical%20evidence (Accessed July 26, 2022).
69. Sarkissian, A. Florida is the only state to skip pre-ordering Covid-19 vaccines for kids. Politico (2022).
71. Florida Department of Health. State surgeon general Dr. Joseph a. Ladapo issues new mRNA COVID-19 vaccine guidance. (2022). Available at: https://content.govdelivery.com/accounts/FLDOH/bulletins/3312697.
72. State of Florida Office of the Governor. Governor Ron DeSantis Petitions Florida Supreme Court for Statewide Grand Jury on COVID-19 Vaccines and Announces Creation of the Public Health Integrity Committee. (2022). Available at: https://www.flgov.com/2022/12/13/governor-ron-desantis-petitions-florida-supreme-court-for-statewide-grand-jury-on-covid-19-vaccines-and-announces-creation-of-the-public-health-integrity-committee/.
73. Governor Ron DeSantis. Petitions Florida Supreme Court for Statewide Grand Jury on COVID-19 Vaccines and Announces Creation of the Public Health Integrity Committee. (2022). Available at: https://www.flgov.com/2022/12/13/governor-ron-desantis-petitions-florida-supreme-court-for-statewide-grand-jury-on-covid-19-vaccines-and-announces-creation-of-the-public-health-integrity-committee/.
74. Sarkasian, A. Florida surgeon general rejects FDA guidance, urges people under 65 not to get Covid booster. (2023). https://www.politico.com/news/2023/09/13/florida-surgeon-general-fda-covid-booster-00115781.
75. Florida Health. Florida State Surgeon General Calls for Halt in the Use of COVID-19 mRNA Vaccines January 3. (2024). https://www.floridahealth.gov/newsroom/2024/01/20240103-halt-use-covid19-mrna-vaccines.pr.html.
76. Coronavirus Response. (2023). Available at: https://trumpwhitehouse.archives.gov/issues/coronavirus/.
77. State of Florida Office of the Governor. Florida leads the nation in vaccines for ages 65+ with seniors first approach. (2021). Available at: https://www.flgov.com/2021/01/20/florida-leads-the-nation-in-vaccines-for-ages-65-with-seniors-first-approach/.
78. Worldometer. Florida Coronavirus Cases. (2023). Available at: https://www.worldometers.info/coronavirus/usa/florida/.
79. Centers for Disease Control and Prevention. Outbreak of pneumonia of unknown etiology (PUE) in Wuhan, China. (2020). Available at: https://emergency.cdc.gov/han/han00424.asp.
80. Holshue, ML, DeBolt, C, Lindquist, S, Lofy, KH, Wiesman, J, Bruce, H, et al. First case of 2019 novel coronavirus in the United States. N Engl J Med. (2020) 382:929–36. doi: 10.1056/NEJMoa2001191
82. Administration for Strategic Preparedness and Response. Administration for Strategic Preparedness and Response. (2023). Available at: https://aspr.hhs.gov/Pages/Home.aspx.
84. Feuer, W. Amid Testing Concerns, US officials unveil new Coronavirus Test Kits and Streamline Commercial Development. CNBC. (2020).
85. Centers for Disease Control and Prevention. CDC confirms possible instance of community spread of COVID-19 in US. (2020). Available at: https://www.cdc.gov/media/releases/2020/s0226-Covid-19-spread.html.
89. Bowen, J. All Florida public schools to close for 2 weeks to limit coronavirus spread. Fox 13 News. (2020).
90. State University System of Florida. State University System Statement on COVID-19. (2020). Available at: https://www.flbog.edu/2020/03/11/state-university-system-statement-on-covid-19/.
91. Sherman, A. Fact-checking a false claim about lockdowns in South Florida cities. Politifact. (2020).
93. Lardieri, A. Florida orders schools to reopen in fall despite rising coronavirus cases. US News and World Report. (2020).
94. Vaughn, C. “20,000 Doses of Hope”: Florida Begins Administering COVID Vaccine. Spectrum News (2020).
95. The Novel Coronavirus Pneumonia Emergency Response Epidemiology Team. The epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (COVID-19) – China. China CDC Wkly. (2020) 2:113–22. doi: 10.46234/ccdcw2020.032
96. Centers for Disease Control and Prevention. Deaths by Select Demographic and Geographic Characteristics. (2023). Available at: https://www.cdc.gov/nchs/nvss/vsrr/covid_weekly/index.htm.
97. Centers for Disease Control and Prevention. Underlying medical conditions associated with higher risk for severe COVID-19: information for healthcare professionals. (2023). Available at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-care/underlyingconditions.html.
98. Kilduff, L, and Which, US. States have the oldest Populations? (2021). Available at: https://www.prb.org/resources/which-us-states-are-the-oldest/.
99. Florida Health Charts. County and State Reports July 26. (2023). Available at: https://www.flhealthcharts.gov/charts/QASpecial.aspx#HS.
100. Centers for Disease Control and Prevention. United States COVID-19 pandemic vulnerability index by county. (2020). Available at: https://stacks.cdc.gov/view/cdc/92735.
101. Florida Health Charts. Nursing Home Beds, July 26. (2023). Available at: https://www.flhealthcharts.gov/ChartsDashboards/rdPage.aspx?rdReport=NonVitalIndNoGrp.Dataviewer&cid=0325.
102. Boodman, E, and Branswell, H. First Covid-19 outbreak in a U.S. nursing home raises concerns. Stat (2020).
103. New York State Department of Health. New York State Department of Health Issues Report On COVID-19 In Nursing Homes. (2020). Available at: https://www.health.ny.gov/press/releases/2020/2020-07-06_covid19_nursing_home_report.htm.
105. CHDG. (2023). Available at: https://www.cdc.gov/publichealthgateway/sitesgovernance/index.html.
106. Florida Department of Health. County Health Department Leadership. (2023). Available at: https://www.floridahealth.gov/about/ssg/chd-leadership/index.html.
107. Schweers, J. Jared Moskowitz, head of Florida emergency management, confirms he's stepping down. Tallahassee Democrat. (2021).
109. Bollyky, Thomas J., Nies, Ashley, and Turilli, Isabella. Did Florida get it right against COVID-19? Think Global Health September 7. (2023). Available at: https://www.thinkglobalhealth.org/article/didd-florida-get-it-right-against-covid-19.
110. ILO. Protective measures for vulnerable populations, gatherings of private citizens and density of the workforce. (2020).
111. Jett, T. Iowa biotech firm says it has produced enough coronavirus tests for 700,000 patients. Des Moines Register (2020).
112. Downey, R. Deborah Birx highlights Florida Department of Health COVID-19 website. Florida Politics (2020).
114. Dawson, A. There’s not much ‘tracing’ in Florida’s COVID-19 contact tracing program. Tampa Bay Times. (2021).
115. The Bioinformatics CRO. States ranked by age-adjusted COVID deaths. (2022). Available at: https://www.bioinformaticscro.com/blog/states-ranked-by-age-adjusted-covid-deaths/.
116. Florida Department of Health. The State of Florida Issues COVID-19 Updates. (2020). Available at: https://www.floridahealth.gov/newsroom/2020/04/041320-2100-covid19.pr.html.
118. NBC Miami. Confirms third coronavirus death at Fort Lauderdale assisted living facility. NBC Miami (2020).
119. Fla, LK. COVID isolation centers received over $50M in state, federal reimbursements data shows. ABC Action News. (2021).
120. Florida Hospital Association. Florida Hospital Association. Available at: https://www.fha.org/.
121. Administration FAFHC. Health Facility Reporting System, July 26. Available at: https://ahca.myflorida.com/health-care-policy-and-oversight/hfrs.
122. Mendenhall, M. DeSantis orders COVID-19 hot spot travelers quarantined on arrival in Florida. Jacksonville Daily Record (2020).
123. Alonso, M, and Cullinanne, S. Florida coronavirus checkpoints screen for motorists from hardest-hit areas. CNN (2020).
124. News Service of Florida. Florida ends COVID-19 checkpoint on I-10; 1-95 checkpoint still in place. News 4 Jax. (2020).
125. Camera, L. Pediatric group calls for children to return to schools despite coronavirus. US News World Rep (2020).
126. Florida Department of Education. Archived guidance and information, July 26. Available at: https://www.fldoe.org/covid-19/info-guidance/archive.stml#plans2021.
127. Baker, S. The CDC held off publishing new guidelines for school reopenings after attacks from the white house. Bus Insid (2020).
128. Schwartz, M, and Diaz, J. CDC cuts the recommended isolation and quarantine periods for coronavirus infections. NPR (2021).
129. Florida Department of Health. COVID-19: summary of cases associated with primary and secondary schools. (2021). Available at: http://ww11.doh.state.fl.us/comm/_partners/covid19_report_archive/school-reports/schools_latest.pdf.
130. Spencer, T, and Licon, A. Florida coronavirus cases jump 50% as surge continues. Associated Press (2021).
131. Doyle, TR, Downey, S, Hurley, ET, Klifto, C, Mullett, H, Denard, PJ, et al. COVID-19 in Primary and Secondary School Settings During the First Semester of School Reopening - Florida, August-December 2020. MMWR Morb Mortal Wkly Rep. (2020) 70:437–41. doi: 10.15585/mmwr.mm7012e2
132. State of Florida Board of Governors. The State University System of Florida Blueprint for Reopening Campuses Fall Semester (2020). Available at: https://www.flbog.edu/wp-content/uploads/BLUEPRINT_May-20_DRAFT2.pdf.
133. State University System of Florida. State University System of Florida: Thanksgiving Break Recommendations. (2020). Available at: https://www.flbog.edu/2020/11/17/state-university-system-of-florida-thanksgiving-break-recommendations/.
135. State of Florida Office of the Governor. Governor DeSantis Issues an Executive Order Ensuring Parents’ Freedom to Choose. (2021). Available at: https://www.flgov.com/2021/07/30/governor-desantis-issues-an-executive-order-ensuring-parents-freedom-to-choose/.
136. Reuters. CDC recommends U.S. schools continue to use masks. (2021). Available at: https://www.reuters.com/world/us/us-schools-should-continue-use-masks-cdc-2021-05-15/.
138. Balingit, M. New Florida order makes quarantine optional for asymptomatic children exposed to virus. Washington Post. (2021).
139. Herper, M. FDA grants authorization to Moderna’s Covid-19 vaccine, the second in the U.S. Stat. (2020).
140. Johnson and Johnson. Johnson & Johnson COVID-19 Vaccine Authorized by U.S. FDA For Emergency Use - First Single-Shot Vaccine in Fight Against Global Pandemic. (2021). Available at: https://www.jnj.com/johnson-johnson-covid-19-vaccine-authorized-by-u-s-fda-for-emergency-usefirst-single-shot-vaccine-in-fight-against-global-pandemic.
141. Gibson, T, Verno, L, and Avanier, E. DeSantis breaks with CDC, says Florida seniors next in line to receive COVID-19 vaccine. News 4 Jax (2020).
142. Mazzei, P, Adelson, E, and Kelly, K. ‘It became Sort of lawless’: Florida vaccine rollout turns into a Free-for-all. New York Times (2021).
143. Downey, R. Top Florida health official issues advisory against ‘vaccine tourism’. Florida Politics (2021).
144. Mathers, S. Florida launches new program to vaccinate homebound seniors, others. Action News Jax (2021).
145. State of Florida Office of the Governor. Governor Ron DeSantis Announces Inter-Faith Vaccine Event, New Pilot to Vaccinate Holocaust Survivors. (2021). Available at: https://www.flgov.com/2021/02/04/governor-ron-desantis-announces-inter-faith-vaccine-event-new-pilot-to-vaccinate-holocaust-survivors/.
146. Bauerlein, D. New Florida grass-roots group aims to overcome black residents distrust of COVID-19 vaccine. Florida Times-Union (2020).
147. New York Times. Covid-19 News: young people crowd a Florida FEMA site in hopes of vaccination. New York Times. (2021).
148. The Covid Vaccine Line Dance. (2021). Available at: https://projects.wuft.org/the-covid-vaccine-line-dance/.
149. U.S. Food and Drug Administration. Coronavirus (COVID-19) update: FDA authorizes Pfizer-BioNTech COVID-19 vaccine for emergency use in adolescents in another important action in fight against pandemic. (2021). Available at: https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-authorizes-pfizer-biontech-covid-19-vaccine-emergency-use.
150. Colombini, S. Schools vaccinating students against COVID as academic year approaches. Tampa, FL: WUSF Public Media (2021).
151. Centers for Disease Control and Prevention. CDC Recommends Pediatric COVID-19 Vaccine for Children 5 to 11 Years. (2021). Available at: https://www.cdc.gov/media/releases/2021/s1102-PediatricCOVID-19Vaccine.html.
152. Li, D, and Duarte, N. Florida surgeon general recommends against Covid vaccination for 'healthy' children. NBC News (2022).
153. Centers for Disease Control and Prevention. CDC Recommends COVID-19 Vaccines for Young Children. (2022). Available at: https://www.cdc.gov/media/releases/2022/s0618-children-vaccine.html#:~:text=Parents%20and%20caregivers%20can%20now,%2D19%2C%20should%20get%20vaccinated.
154. CDC. Stay up to date with COVID-19 vaccines. (2024). https://www.cdc.gov/coronavirus/2019-ncov/vaccines/stay-up-to-date.html.
155. Centers for Disease Control and Prevention. Variants (2023). Available at: https://www.cdc.gov/coronavirus/2019-ncov/variants/index.html.
156. Katella, K. Omicron, Delta, Alpha, and more: what to know about the coronavirus variants. Yale Medicine (2023).
158. Holcombe, M, and Waldrop, T. More infectious Delta variant makes up 83% of new US coronavirus cases as vaccine hesitancy persists. CNN. (2021).
159. Lopez Bernal, J, Andrews, N, Gower, C, Gallagher, E, Simmons, R, Thelwall, S, et al. Effectiveness of Covid-19 vaccines against the B.1.617.2 (Delta) variant. N Engl J Med. (2021) 385:585–94. doi: 10.1056/NEJMoa2108891
160. Man, A. In most of Florida, COVID vaccinations lag where Trump support is highest. Sun Sentinel (2021).
161. Florida Health. Florida COVID-19 Vaccine Tracker. (2021). Available at: https://data.democratandchronicle.com/covid-19-vaccine-tracker/florida/12/.
162. Anderson, M. 68 Florida hospitals have less than 2 days of oxygen, survey finds. Becker’s hospital Review (2021).
163. Florida Office of the Governor. Governor Ron DeSantis Announces Expanded Monoclonal Antibody Access in Florida with New Monoclonal Antibody Centers. (2021). Available at: https://www.flgov.com/2021/08/12/governor-ron-desantis-announces-expanded-monoclonal-antibody-access-in-florida-with-new-monoclonal-antibody-centers/.
164. Florida Office of the Governor. Governor Ron DeSantis Highlights Monoclonal Antibody Treatment Success in Florida. (2021). Available at: https://www.flgov.com/2021/10/14/governor-ron-desantis-highlights-monoclonal-antibody-treatment-success-in-florida/.
165. Tribune News Service. Floridians embrace COVID-19 antibody treatment. United States: Tampa Bay Times (2021).
167. U.S. Food and Drug Administration. Coronavirus (COVID-19) update: FDA limits use of certain monoclonal antibodies to treat COVID-19 due to the Omicron variant. (2022). Available at: https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-limits-use-certain-monoclonal-antibodies-treat-covid-19-due-omicron.
168. Covid ActNow. U.S. COVID Tracker. (2023). Available at: https://covidactnow.org/?s=47273475.
169. Centers for Disease Control and Prevention. Deaths by Week and State (2023). Available at: https://www.cdc.gov/nchs/nvss/vsrr/covid19/index.htm.
170. Sah, P, Moghadas, SM, Vilches, TN, Shoukat, A, Singer, BH, Hotez, PJ, et al. Implications of suboptimal COVID-19 vaccination coverage in Florida and Texas. Lancet Infect Dis. (2021) 21:1493–4. doi: 10.1016/s1473-3099(21)00620-4
174. Tampa Bay. Ron DeSantis announces 1 million Hydroxychloroquine doses are headed to Florida from India. (2020). Available at: https://www.youtube.com/watch?v=EHMzzReCv4E.
176. Pradelle, A, Mainbourg, S, Provencher, S, Massy, E, Grenet, G, and Lega, JC. Deaths induced by compassionate use of hydroxychloroquine during the first COVID-19 wave: an estimate. Biomed Pharmacother. (2024) 171:116055. doi: 10.1016/j.biopha.2023.116055
179. Ballotpedia. States that issued lockdown and stay-at-home orders in response to the coronavirus (COVID-19) pandemic. (2020). Available at: https://ballotpedia.org/States_that_issued_lockdown_and_stay-at-home_orders_in_response_to_the_coronavirus_(COVID-19)_pandemic,_2020.
181. Selig, D, and Finnie, A. Palm Beach can start reopening Monday; Miami-Dade and Broward target May 18. Local 10 News (2020).
182. Tallahassee Democrat. Read the order for Florida schools to open in august|document. Tallahassee Democrat. (2020).
183. Rozsa, L, Balingit, M, and Strauss, V. A Florida school district wanted to wait to reopen school buildings. Gov. Ron DeSantis threatened to cut its funding. Washington Post (2020).
184. Sparks, G. Democrats and republicans split on accuracy of coronavirus death statistics, polling shows, 2020. (2020). Available at: https://www.cnn.com/2020/05/26/politics/coronavirus-death-toll-statistics-poll-gallup/index.html.
185. Vazquez, M. Trump now says he wasn’t kidding when he told officials to slow down coronavirus testing, contradicting staff. CNN (2020).
186. Conarck, B, and Nehamas, N. DeSantis office ‘leaks’ Florida records to fuel COVID-19 death ‘conspiracy’. Tampa Bay Times (2020).
187. Gonsalves, G. Herd immunity: Covid deaths devouring the south are no accident. The Nation (2021).
188. Tampa Bay. Florida governor suspends collection of fines for violating local mask rules. Tampa Bay (2020).
189. Avlon, J, Warren, M, and Miller, B. Atlas push to ‘slow the testing down’ tracks with dramatic decline in one key state. CNN. (2020).
190. Floridians for Government Accountability. Desantis covid measures and the free state of Florida. (2023). Available at: https://www.accountabilityflorida.org/desantis-covid-measures.html.
191. LeBlanc, P. Biden and Obama urge Americans to get vaccinated in star-studded television special. CNN. (2021).
192. Pettypiece, S. Biden pushes Americans to reach goal of 70 percent vaccinated adults by July 4. NBC News (2021).
194. Graham, K. LIFEGOP embraces the ‘natural immunity’ card to get around vaccine mandates. Digital Journal (2021).
195. Murillo-Zamora, E, Trujillo, X, Huerta, M, Rios-Silva, M, Guzman-Esquivel, J, Benites-Godinez, V, et al. COVID-19 vaccines provide better protection against related pneumonia than previous symptomatic infection. Int J Infect Dis. (2022) 120:142–5. doi: 10.1016/j.ijid.2022.04.047
196. Team C-F. Past SARS-CoV-2 infection protection against re-infection: a systematic review and meta-analysis. Lancet. (2023) 401:833–42. doi: 10.1016/S0140-6736(22)02465-5
198. Bella, T. Speakers at DeSantis news conference promoted false vaccine claims while governor stood. Washington Post (2021).
199. News Service of Florida. Governor's office: Florida will no longer release daily COVID-19 case, death reports. Tallahasee Democrat (2021).
201. Florida Department of Health. COVID-19 Vaccine PSA – Statewide. (2021). Available at: https://www.youtube.com/watch?v=H5B8tomkIWc.
202. Mueller, B. They shunned Covid vaccines but embraced antibody treatment. New York Times (2021).
203. McLean, J. DeSantis downplays COVID-19, says other respiratory diseases pose greater health risk. News 4 Jax (2021).
204. Sarkissian, A. Florida surgeon general altered key findings in study on Covid-19 vaccine safety. Politico (2023).
206. Harding, A, Vasilinda, M, and Verno, L. $5,000 fine for ‘vaccine passports’ in Florida takes effect today. News 4 Jax. (2021).
207. Schulz, B. Vaccine passports: Norwegian cruise line holdings sues Florida over vaccine passport ban. USA Today (2021).
208. Federal, WJ. No factual or legal basis to prohibit Norwegian cruise line holdings from requiring proof of COVID-19 vaccine. Cruise Law News (2021).
209. Fineout, G. Biden tells DeSantis to ‘get out of the way’ amid Covid surge. Politico August 3. (2021). https://www.politico.com/states/florida/story/2021/08/03/desantis-blames-media-for-hysteria-over-covid-surge-1389404.
210. WESH. 'I am standing in your way': DeSantis blasts Biden after president tells him to 'get out of the way' on COVID. (2021). Available at: https://wesh.com/article/watch-live-gov-desantis-and-deo-secretary-provide-update-on-state-of-floridas-economy/37223004.
211. Quesada, M, and Sutton, S. Ron DeSantis won't enforce supreme Court's ruling impacting COVID-19 vaccines for health care workers. WPTV (2022).
212. Florida, AZ. DeSantis asks high school students to remove masks at event: 'This is ridiculous'. USA Today (2022).
213. Grossenbacher, K, and Shaw, S. Florida governor signs into law sweeping bill that prohibits businesses from discriminating based on vaccination status or from requiring face masks and COVID-19 tests. JD Supra (2023).
214. Guidance for COVID-19 Boosters. (2023). Available at: https://floridahealthcovid19.gov/wp-content/uploads/2023/09/20230913-booster-guidance-final.pdf.
215. Leonard, K. Ladapo campaigns with DeSantis in New Hampshire. (2023). https://www.politico.com/newsletters/florida-playbook/2023/11/01/ladapo-campaigns-with-desantis-in-new-hampshire-00124681 (Accessed November 1, 2023).
216. Indiana Governor’s Public Health Commission Report. (2022). https://www.in.gov/health/files/GPHC-Report-FINAL-2022-08-01.pdf (Accessed August 1, 2022).
Keywords: pandemic, COVID-19, policy, vaccine, Florida, public health
Citation: Rivkees SA (2024) The shifting impact and response to COVID-19 in Florida. Front. Public Health. 12:1351690. doi: 10.3389/fpubh.2024.1351690
Edited by:
Hongping Yuan, Guangzhou University, ChinaReviewed by:
Ranjit Kumar Dehury, University of Hyderabad, IndiaSusan M. Swider, Rush University, United States
Copyright © 2024 Rivkees. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Scott A. Rivkees, srivkees@brown.edu