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While Illinois is still about 10 days away from reaching its projected peak of hospitalizations (according to the IHME study) and about two months away from reaching its projected peak (according to the COVID Act Now study), health care experts, economists, and the general public are beginning to wonder what happens next.
In its March 16 report, the Imperial College Response Team warned that there may be a resurgence in COVID-19 cases if restrictions imposed to contain the spread of the virus are lifted. The report says, “To avoid a rebound these policies [population-wide social distancing combined with home isolation of COVID-19 cases and school and university closure] will need to be maintained until large stocks of vaccine are available to immunize the population – which could be 18 months or more.”
A number of health care experts are expressing similar concerns about a potential resurgence of COVID-19 cases if restrictions are lifted – although they suggest the cycle may end when either a vaccine is discovered or an effective drug treatment is discovered.
An important issue is what the nation and states should do before they lift stay-at-home orders and social distancing – so they will be prepared to address a potential recurrence of COVID-19 cases.
One report called “National Coronavirus Response, A ROAD MAP TO REOPENING,” says the nation should be opened in four phases, and it lists a number of essential steps to be taken in each phase.
The March 28 report was prepared by five people, two former commissioners of the Food and Drug Administration, one former deputy director of the Food and Drug Administration, and one professor and an assistant professor at Johns Hopkins Center for Health Safety.
Phase I – Reduce the Spread, Prepare Infrastructure
The nation is in Phase I. With some variations, most states have closed schools, closed non-essential businesses, entered stay-at-home orders, and implemented social distancing.
“These measures will need to be in place in each state until transmission has measurably slowed down,” says the report. Before moving to Phase II, there must be a “sustained reduction in cases for at least 14 days.”
Importantly, the report also says that during Phase I, the infrastructure “to safely manage the outbreak and care for the sick” must be scaled up.
In essence, the states have been attempting to contain the spread of COVID-19 by implementing community-wide measures, such as by closing schools, closing non-essential businesses and gathering places, and entering stay-at-home orders. If states end some or all of these limitations, they must be prepared to deal with new cases of COVID-19 and the spread of those cases in a different way.
Conceptually, shutting down communities may have contained the spread of COVID-19 to a point where the health care systems can in the future begin to contain the disease by focusing on individual patients and the people they have been in contact with. The states, though, need to have an infrastructure in place to do that.
Some things the report says need to be done are the following.
First, Increase Diagnostic Testing Capacity and Build Data Infrastructure for Rapid Sharing of Results.
The report says ramping up capacity to test for COVID-19 is essential to move from “community-wide interventions that focus on large populations to case-based interventions that target and isolate individual people who are infected.”
The health care system must have capacity to test hospitalized patients, health care workers and workers in essential roles, people in close contact with people who have tested positive for COVID-19 and outpatients with symptoms.
“We estimate that a national capacity of at least 750,000 tests per week would be sufficient to move to case-based interventions when paired with sufficient capacity in supportive public-health infrastructure (e.g., contact tracing).
“In conjunction with more widespread testing, we need to invest in new tools to make it efficient for providers to communicate test results and make data easily accessible to public-health officials working to contain future outbreaks.”
Second, Hospitals must have capacity to treat all patients requiring hospitalization without resorting to crisis standards of care.
The report says the hospitals should have “sufficient critical-care capacity … to be able to immediately expand capacity from 2.8 critical-care beds per 10,000 adults to 5–7 beds per 10,000 adults in the setting of an epidemic or other emergency, allowing for regional variation. This target is a minimum, must be adequate for the current and forecasted level of demand, and must be accompanied by adequate staffing.”
The report also says there should be at least 30 acute-care hospital beds per 10,000 adults.
In addition, the number of ventilators in hospitals must be increased from 3 per 10,000 adults to a goal of 5-7 ventilators per 10,000 adults. This target is a minimum, and must be accompanied by adequate staffing.
“Facilities should have a plan, in the case of a surge in hospital demand, for how the beds would be rapidly flexed from more discretionary uses (e.g., elective procedures) and adequately staffed, with access to adequate supplies of oxygen and other medical supplies,” says the Report.
Third, Implement Comprehensive COVID-19 Surveillance Systems.
“The move toward less restrictive physical distancing could precipitate another period of acceleration in case counts,” says the report. “Careful surveillance will be needed to monitor trends in incidence.”
The report says, “The CDC should convene an intergovernmental task force, with outside experts as needed and input from states and the health care community, to develop and support a new national surveillance system and data infrastructure for tracking and analyzing COVID-19.
“When a new case of COVID-19 is diagnosed, the patient should be isolated either at home or in a hospital, depending on the level of care he or she requires. Current CDC guidelines recommend seven days of isolation. Home isolation can be enforced using technology such as GPS tracking on cell phone apps.
“Also, the close contacts of confirmed cases (as defined by the CDC16) should be quarantined and monitored daily for 14 days. Monitoring of international travelers is also recommended. To scale these interventions to accommodate thousands of daily cases and tens of thousands of daily contacts, public-health infrastructure will need to be dramatically scaled up throughout the country, in coordination with the improving capacity of health care providers to prevent, diagnose, and treat COVID-19 cases.”
The report says the above four measures should be in place before moving to Phase II.
Phase II – Reopening Schools and Businesses
“During this phase, schools and businesses can reopen, and much of normal life can begin to resume in a phased approach.” These changes should be done in conjunction with increased testing for new cases.
In addition, the report says some physical distancing measures and limitations on gatherings will still need to be in place to prevent transmission from accelerating again. For older adults (those over age 60), those with underlying health conditions, and other populations at heightened risk from COVID-19, continuing to limit time in the community will be important,” says the report. People may initially be asked to wear face masks.
“Those who are sick will be asked to stay home and seek testing for COVID-19. Testing should become more widespread and routine as point-of-care diagnostics are fully deployed in doctors’ offices.
“A state should revert to Phase I and continue to slow the spread” if a substantial number of cases cannot be traced back to known cases, if there is a sustained rise in new cases for five days, or if hospitals in the state are no longer able to safely treat all patients requiring hospitalization.
Phase III – Removal of Other Restrictions
In Phase III, the report says, “Physical distancing restrictions and other Phase II measures can be lifted when safe and effective tools for mitigating the risk of COVID-19 are available, including broad surveillance, therapeutics that can rescue patients with significant disease or prevent serious illness in those most at risk, or a safe and effective vaccine.”
Phase IV – Never Again
“After we successfully defeat COVID-19, we must ensure that America is never again unprepared to face a new infectious disease threat. This will require investment into research and development initiatives, expansion of public-health and health care infrastructure and workforce, and clear governance structures to execute strong preparedness plans. Properly implemented, the steps described here also provide the foundation for containing the damage that future pathogens may cause.”
Much remains to be done.
The authors of the report are Scott Gottlieb, MD; Caitlin Rivers, PhD, MPH; Mark B. McClellan MD, PhD; Lauren Silvis, JD; and Crystal Watson, DrPh, MPH