By Rachel-Paige Casey
Throughout April, strategies regarding the reopening of the US economy and its associated public health factors were published by the White House with the Centers for Disease Control and Prevention (CDC), the Center for Health Security at Johns Hopkins University, the Rockefeller Foundation, and the Edmond J Safra Center for Ethics at Harvard University. The four strategies discussed here either outline phases for resuming activity or describe systems to enable and assist safe reopening. All these plans consider the importance of testing to continue slowing the spread of COVID-19 as normal life gradually resumes. Other nations, such as South Korea, have successfully built high-capacity testing and tracing infrastructures in the wake of COVID-19. Unfortunately, the US has failed to develop its own robust testing and tracing system. At present, US testing capacity has plateaued at about 150,000 tests per day, equating to a little over 1 million tests per week, a figure deemed insufficient by experts in public health and medicine.
Further, all plans identify the need to consider vulnerable populations as activity is gradually resumed and countermeasures, such as distancing, are eased. It is worth noting that a substantial proportion of the US population is likely classified as vulnerable. Regarding cardiovascular issues, almost half of the US population is considered hypertensive and nearly 16 million have been diagnosed with chronic obstructive pulmonary disease (COPD). According to the CDC, about 42% of American adults are considered obese along with almost 14 million children and adolescents. Additionally, over 100 million adults suffer from diabetes or prediabetes. Much of the variation across these plans lies in the differing degrees of details for its strategies, guidelines, criteria, thresholds, and definitions regarding reopening and testing.
By end of May, 33 states will have already begun to open up their economies by relaxing social distancing and shelter-in-place measures. These relaxations vary across states in terms of public space capacity limitations, specific requirements for sanitation and hygiene, and categories of businesses allowed to resume operations at certain levels. The fear with opening up is its potential to invite a resurgence of COVID-19 cases. Though no “perfect fit” plan can be created, especially under such uncertain and tumultuous conditions, leaders across the jurisdictional spectrum need empirically-based guidance and goals that help their populations return to “normal” life. The four plans discussed below seek to provide such guidance.
Opening Up America Again
The White House and CDC’s Guidelines for Opening Up America Again proposes a three-phase plan for individuals and employers to progress through economic and societal reopening based on a state or region meeting gating criteria. The gating criteria that a state or region should meet before progressing to the next phase of opening are based on symptoms, cases, and treatment. More specifically, the criteria are: (1) downward trajectories of influenza-like illnesses (ILI) and COVID-like syndromic cases over a 14-day period; (2) downward trajectory of documented cases or of positive tests as a percent of total tests (flat or increasing volume of tests) over a 14-day period; and (3) hospitals should be treating all patients without crisis care and maintaining a robust testing program for at-risk healthcare workers. The White House-CDC guidelines tend to lack detail and instructions, specifically regarding vulnerable populations, special accommodations, testing systems, and robust contact tracing.
Across all three phases, individuals are encouraged to practice good hygiene: wash hands regularly, avoid touching your face, disinfect shared items and surfaces, and wear face coverings in public. Individuals are also advised to stay home and seek medical attention if they “feel sick.” Additionally, employers are directed to implement or continue policies for social distancing, personal protective equipment (PPE), sanitation, disinfection, testing and tracing, and travel. Employers are also encouraged to monitor their workforces for ILL and COVID-19-like symptoms. Put simply, the onus of syndromic monitoring and contact tracing is largely placed on employers. The full plan from the White House and CDC is available here.
Phase 1 is essentially a soft re-entry of low risk individuals into limited economic and social activity. These guidelines consider vulnerable individuals to include the elderly (an age threshold for this designation is not stated), immunocompromised individuals, and individuals with health issues such as hypertension, chronic lung disease, diabetes, asthma, and those who are obese. When in public, all individuals should keep their distance and limit social events to a maximum of 10 persons when physical distancing cannot be easily maintained. Non-essential travel for both personal and professional reasons is still discouraged.
Employers should continue to encourage telework whenever possible and gradually reintroduce employees to on-site work so that physical distancing can be maintained. Further, employers are encouraged to consider special accommodations for personnel considered vulnerable; however, the specifics regarding what the special accommodations are and how to implement them are not detailed. Schools, daycares, camps, and bars should remain closed, but large venues – such as dine-in restaurants, movie theatres, and sports venues – and gyms can operate under strict distancing rules. Visitors to senior living facilities and hospitals should remain prohibited, but elective surgeries can resume on an outpatient basis.
As in Phase 1, all vulnerable persons should continue to shelter-in-place and should take precautions to isolate themselves from close contacts that are returning to public places. When in public, all individuals should maintain physical distance, but the socializing cap is raised to 50 persons. Also, non-essential travel for both personal and professional reasons can resume. Employers should continue to allow telework, if possible, and maintain an environment conducive to distancing. Schools, daycares, and camps can reopen. Bars can operate at a limited level. Large venues can now relax to moderate distancing rules. Elective surgeries can now expand to include in-patient procedures.
Finally, as a state or region enters the final phase, vulnerable individuals can resume public interactions, but should consider minimizing time spent in crowded spaces. Worksites can resume unrestricted staffing. Large venues, gyms, and bars can operate under standard or heavily relaxed protocols for sanitation and distancing. Visits to senior care facilities and hospitals can resume with stringent hygiene protocols.
Public Health Principles for a Phased Reopening During COVID-19: Guidance for Governors
The Center for Health Security at Johns Hopkins University published its Public Health Principles for a Phased Reopening During COVID-19: Guidance for Governors to evaluate the risk of COVID-19 transmission in the reopening of nonessential public spaces. This plan is based on the American Enterprise Institute’s National Coronavirus Response: A Road Map to Reopening, which outlines four phases, details the capacities required in each phase, and identifies the triggers needed to advance to the next phase. According to the guidelines, a state should consider starting the next phase of reopening when they have met four criteria: (1) the number of new cases has declined for at least 14 days; (2) rapid diagnostic testing capacity is sufficient to test all individuals with COVID-19 symptoms, close contacts, and essential personnel; (3) the healthcare system can safely care for all patients and provide PPE for healthcare workers; and (4) there is sufficient public health capacity to perform contact tracing for all new cases and their close contacts.
Phase I of the Road Map focuses on physical distancing and shelter-in-place to continue slowing the spread of coronavirus, with state leaders working to increase testing access and healthcare capacity for its citizens. Simultaneously, efforts should be underway to stabilize essential sectors via swift testing and isolation for positive cases, retraining nonessential workers to temporarily replace coronavirus-positive essential workers, and improving standards for infection and hygiene control. Phase II can be entered upon meeting four criteria: (1) decline in new cases for at least 14 consecutive days; (2) rapid diagnostic testing capacity is, at minimum, available for all individuals presenting with COVID-19 symptoms, close contacts to confirmed cases, and essential personnel; (3) the healthcare system is capable of safely caring for all patients; and (4) public health capacity is sufficient to conduct contact tracing for all new cases and associated close contacts. Phase II marks the beginning of sectoral opening under limitations and modifications, along with the relaxation of shelter-in-place mandates. Phase III looks toward the future in which a safe and effective therapeutic and vaccine become available. Finally, Phase IV isolates policy priorities to improve preparedness for the next outbreak. In-depth descriptions of the goals, thresholds, steps, and triggers for each of the four phases can be found in the full report here.
The Guidance for Governors recognizes that there is no one-size-fits-all approach to reopening, so Governors and other state leaders must assess their epidemiologic and economic circumstances in order to best make decisions and take action. These assessments may reveal that changes need to occur on a more localized basis, such as at the county level. As decisions are made and changes are enacted, communication to the public must be both clear and consistent. Feedback should also be a major component of a state or community’s communication strategy, encouraging and enabling engagement between citizens and decision-makers.
The bread and butter of the Guidance for Governors is its guidelines for conducting risk assessments and interpreting the findings in order to make informed decisions. A risk assessment of easing social distancing measures and resuming economic activity entails measuring the likelihood of increased transmission and magnitude of consequences that increased transmission may have on individuals and communities. Despite limited data and understanding about the transmission dynamics of the novel coronavirus, we do know that crowded settings increase the possibility and coverage of transmission. The National Institute for Occupational Safety and Health (NIOSH) designed a hierarchy of control for potential workplace hazards that can be used to assess the efficacy of COVID-19 controls in workplaces. The COVID-19 adapted hierarchy includes physical distancing, engineering controls, administrative controls, and PPE. The Guidelines include three-dimensional high-level risk assessments for seven categories of settings: (1) “nonessential” businesses, (2) schools and childcare facilities, (3) outdoor spaces, (4) community gathering spaces, (5) transportation, (6) mass gatherings, and (7) interpersonal gatherings. The three risk dimensions are contact intensity, number of contacts, and the degree to which the activities are considered to be modifiable with measures such as distancing. Within each setting category, the subtypes – such as restaurants or gyms as types of nonessential businesses – are assessed as low, medium, or high risk. For each subtype, mitigation resource materials are provided for additional assistance.
National COVID-19 Testing Action Plan
The Rockefeller Foundation’s National COVID-19 Testing Action Plan comprises three major objectives to break from the testing capacity plateau: (1) launch a 1-3-30 Plan to significantly expand COVID-19 testing; (2) launch a COVID-19 Community Healthcare Corps for testing and contact tracing; and (3) create a COVID-19 data commons and digital platform. Ultimately, the Action Plan aims to build a state-led nationwide COVID-19 testing system that protects the public through the process of reopening via workforce monitoring, rapid detection of repeated outbreaks, and testing. The Action Plan defines the new entities needed for each objective and lists the steps and activities for creating those entities.
The 1-3-30 Plan comprises three main goals: (1) establishing a coordinating entity, the Emergency Network for COVID-19 Testing; (2) debuting an 8-week National Testing Laboratory Optimization Initiative to boost testing capacity from 1 million to 3 million tests per week; and (3) funding a Testing Technology Accelerator as a public-private partnership to further boost testing capacity to 30 million tests per week. The Emergency Network for COVID-19 Testing (ENCT) will engage with the producers of testing equipment, reagents, and other laboratory products; funders of public and private healthcare facilities and efforts; and financial institutions. Through engagement, the ENCT will seek to identify and remedy choke points in the supply chain for diagnostics. The 8-week National Testing Laboratory Optimization Initiative will reach its goal of boosting testing capacity to 3 million tests per week by utilizing existing testing capacity left dormant in our national, university, and local laboratories. The baton will then be passed to the Testing Technology Accelerator, which will further heighten testing capacity to 30 million tests per week within the following 6 months.
COVID Community Healthcare Corps (CCHC)
The CCHC would exist within state public health departments to augment personnel and equipment to distribute, administer, and oversee testing. The Foundation estimates that 100,000 to 300,000 workers must be hired to successfully launch the CCHC. Tandem to the CCHC, a national system to track the COVID-19 status of individuals is proposed; however, the how-to for striking a balance between individual privacy and the public good is not specifically detailed. Such a system could be quite helpful for contact tracing, but the concerns regarding privacy and access to sensitive information may render this idea improbable. More realistically, the CCHC would try to incentivize the use of voluntary apps and privacy-protected tracking software to support more robust contact tracing.
COVID-19 Data Commons and Digital Platform
The transparent and efficient sharing of data accelerates response and treatment efforts in ongoing outbreaks and in the preparation for future outbreaks. The proposed COVID-19 Data Commons and Digital Platform would enable real-time analysis of resource allocations, infection tracing results, and patient medical records. The Action Plan encourages that data from federal, state, and private platforms be open and available whenever and wherever possible. The integration of health-related digital technologies into surveillance and detection systems is encouraged. Specifically, the Commons would seek to improve the collection of health data through technologies that track health indicators, like body temperature, or rapidly update epidemiological data for improved modeling. The Action Plan also recommends the aggregation of anonymized data from electronic medical records and insurance claims for examination in order to enhance COVID-19 diagnostics and treatment.
Roadmap to Pandemic Resilience
The Edmond J. Safra Center for Ethics at Harvard University published its Roadmap to Pandemic Resilience, a plan to phase in economic mobilization between now and August while simultaneously (though belatedly) scaling up a testing and contact tracing regime. The core concepts within the Roadmap seek to quell the ongoing pandemic but also build up pandemic resilience against the next pathogen. The phases begin with a focus on the essential workforce, which comprises 40% of the population, and gradually expands to include the entire US workforce. The foundation of the Roadmap is testing, tracing, and supported isolation (TTSI). The first three phases of reopening depend on freely and widely available COVID-19 tests and rigorous contact tracing. The Roadmap includes several strategies for pandemic resilience ranging from mass testing and contact tracing systems to innocuous approaches such as voluntary peer-to-peer warning sharing apps to more complicated concepts such as certification systems that provide proof of health from COVID-19 infection.
4 Sectoral Phases
Phase 1 serves as a dry run for the proceeding phases as essential sectors try to stabilize while maintaining physical distancing measures. First and foremost, essential workers who are possibly infected should be identified, treated, and supported. Nonessential workers should be retrained to temporarily replace sick or possibly sick essential workers. Infection control in the workplace would be heightened via mass testing but also contact tracing to identify those who came in close contact with COVID-19 positive workers. Workplaces will also need to employ new and improved standards of hygiene and infection control to limit further spread across their workforces. Phase 2 continues to address shortages in the essential sectors through Phase 1 activities, but expands the definition of essential workers to add another 15% of the workforce. specifically, Phase 2 would focus on medium- and long-term essential workers such as those in maintenance and construction of essential facilities. Phase 2 should see about 55-70% of the workforce able to safely return to work with mass testing systems maintained. Additionally, distancing measures can be eased to milder limitations. Phase 3 commences when about 70% of the workforce can return to work with continued testing and certification systems. At this point, regulations would be relaxed so that these workers can modify their business practices to better serve clients who remain isolated (ex: expansion of home delivery services). Arguably, some expansions could occur earlier in the reopening process to better enable vulnerable populations or infected individuals to remain isolated for their own health and the health of others. Phase 4 should see the return of the remaining isolated workforce and the reopening of schools. The Roadmap’s details for sectoral phasing as well as the roles of businesses, workers, and society can be found here.
Plans in Practice
Dr. Caitlin Rivers, Senior Scholar at the Johns Hopkins Center for Health Security, recently stated that none of the states opening up meet the requirements of the White House guidelines. This is especially concerning given that the White House guidelines are, arguably, the least specific and stringent among the plans considered here. Admittedly, no plan can provide perfectly customized and granular instructions for each state or region, but generalizable thresholds and milestones for reverse triggering pandemic countermeasures and resuming normal activity can be, at least, partially outlined. As states open up, the effects of their decisions on the health of both the public and the economy will provide further insight into preparedness, response, and recovery for the next biological event. Given the many uncertainties surrounding the virus, every federal and state leader is operating with limited information and a bevy of possibilities; however, all leadership should look to experts in public health, medicine, economics, human behavior, and policy to help shape their decisions and actions for the health and safety of the population.