States across the US are extending lockdown orders to slow the spread of COVID-19, the respiratory disease caused by the novel coronavirus. Schools and businesses are shuttered. Major events, including the Democratic National Convention and college basketball's March Madness tournament, have been postponed or called off. Millions of people are out of work.
Amid the upheaval, a panel of experts has begun to examine what it will take to reopen America. Rather than forecast when that might happen, the group identified the conditions the country needs to meet before it can restore something approximating normalcy. The conditions include adequate testing for COVID-19, ensuring that hospitals can treat all patients and pinpointing individuals who have been in contact with someone infected with the disease. Crucially, the team wants to see a sustained decrease in coronavirus cases for at least 14 days, the maximum incubation time for infection.
The recommendations were included in the National Coronavirus Response report, which includes former Food and Drug Administration commissioners Scott Gottlieb and Mark McClellan as authors. The report was published on March 28 by the American Enterprise Institute, a conservative think tank.
Getting the country back to work won't come all at once but will roll out over four stages, the authors say. The first phase, which we're currently in, involves slowing the spread of COVID-19 by maintaining physical distancing, closing schools and businesses and asking people to work remotely. It also calls for an increased capacity to test and diagnose people who have potentially been exposed, such as health care and other essential workers. The report calls for an expansion of critical-care hospital beds and access to ventilators, as well as increased supplies of personal protective equipment for health care workers. (Everyone should be encouraged to wear nonmedical fabric face masks when in public, the authors say.)
"These measures will need to be in place in each state until transmission has measurably slowed down and health infrastructure can be scaled up to safely manage the outbreak and care for the sick," they write.
The authors of the AEI report aren't the only people contemplating how and when to get the US moving again. California Gov. Gavin Newsom and former CDC director Dr. Tom Frieden have shared similar proposals. The World Health Organization updated its guidance to outline six conditions for reducing transmission to include sufficient public health capacity to handle COVID-19 outbreaks and measures to prevent workplace spread.
The White House has also presented guidelines for reopening the nation, a priority for President Donald Trump. Its three phases run from continued remote work and physical distancing for vulnerable individuals to schools reopening and nonessential travel resuming. The last phase of the White House plan is allowing vulnerable individuals to participate in public interactions and permitting employers to staff work sites without restrictions.
The AEI's four-stage plan is among the most detailed to date. States can move to the second phase, in which the majority of schools and businesses reopen, when they can safely diagnose, treat and isolate patients who have contracted COVID-19 and anyone they've come in contact with.
The next phase
To prevent another wave of outbreaks, states should only move to this second phase when they report a sustained decrease in cases for at least 14 days. In addition, local hospitals must be able to safely treat all patients who need to be hospitalized "without resorting to crisis standards of care." States must have the capacity to test everyone with COVID-19 symptoms and actively monitor all confirmed cases and their contacts.
Farzad Mostashari, who founded Aledade, a company that helps primary care practices provide care at lower costs, and who co-authored a companion article on achieving COVID-19 containment, says the US first needs to ensure there are enough tests for health care workers and people who are symptomatic. That means it needs to significantly ramp up capacity from a couple million tests a month to that many per week.
To keep transmission rates from rising during the second phase, some measures adopted during the early stage of the physical distancing measures will need to remain in place, the report says, emphasizing the need for remote work and social gatherings limited to fewer than 50 people.
"If we just go back to doing what we were doing before," Mostashari said, "we're almost certainly going to see the epidemic flare up again."
Phase Two involves identifying people who are immune to COVID-19. Some say widespread serological testing, which identifies who's been exposed to the disease, can pinpoint people with immunity and allow them to return to work. But the WHO has warned there's no evidence these tests show immunity. Rather, organization leaders say, serological tests can measure the level of antibodies in a person, but that doesn't necessarily indicate they're immune.
Getting back to work
Trump has emphasized restarting the economy as soon as possible. At the end of March, he suggested the country be "opened up" by Easter. The federal government later extended social distancing guidelines to April 30. Vice President Mike Pence has suggested social distancing measures likely won't end anytime soon.
Vivian Ho, a health economist at Rice University, said opening up too soon would risk overwhelming both the health care system and its workers.
"Doctors are not robots," Ho said. "We have to demonstrate to them that we're doing everything possible, otherwise we lose the people who will eventually save our lives."
States can move to the AEI's third phase once a vaccine has been developed, tested and granted FDA emergency use authorization.
Lifting restrictions and preparing for the next outbreak
After a vaccine or therapeutic is shown to be safe and appears to be effective, the authors of the report say the US government should work with private industry to plan for wide-scale manufacturing, distribution and administration. Once a "sufficiently high fraction" of the population becomes immune to the disease either via natural recovery or vaccination, remaining restrictions can be lifted.
Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases and member of the White House Coronavirus Task Force, said earlier this month that it's possible for a vaccine to be available a couple months sooner than the 12 to 18 months that have been forecast. But he cautioned not to be overly optimistic.
"You don't want to overpromise," told the CBS Evening News. "We'll just have to see how it goes." (Disclosure: CBS and CNET are owned by the same parent company, ViacomCBS.)
The fourth and final phase of the report centers on rebuilding the nation's readiness for the next pandemic. The US should aim to quickly develop countermeasures for new health threats in months rather than years, the authors say. It should also work to modernize and strengthen the health care system. This includes improving hospital bed and ICU capacity to accommodate a surge of patients and expanding the supply chain of personal protective equipment.
"This is not an economic problem. This is a virus problem," Mostashari said. "The best way to get our economy back is to invest in fighting the outbreak."
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The information contained in this article is for educational and informational purposes only and is not intended as health or medical advice. Always consult a physician or other qualified health provider regarding any questions you may have about a medical condition or health objectives.