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A comprehensive, evidenced-based plan is needed to re-open the economy to prevent a second wave of infections. This is the conclusion of “A National and State Plan to End the Coronavirus Crisis,” a report published in early April by the Center for American Progress.
The Center for American Progress is an independent nonpartisan think tank, “dedicated to improving the lives of all Americans, through bold, progressive ideas, as well as strong leadership and concerted action,” according to its website.
The report, co-authored by a multi-disciplinary team of policy experts, outlines the risks of pre-maturely ending social distancing policies and details the precautions and measures necessary to lift restrictions and re-open the economy.
The plan recommends the following:
- Continue a stay-at-home-policy until at least late May to suppress community transmissions and buy time to implement other measures.
Studies show that physical distancing is effective in slowing the spread of the COVID-19, notes the report. However, there is currently no national policy in place.
When the report was written, 11 states (five as of today, April, 15th) had not issued stay-at-home orders or closed nonessential businesses, increasing the risks of outbreaks and accelerating cases. The authors recommend “a consistent national policy be put in place for a sufficient time period in order to suppress transmissions to levels that would allow the easing of restrictions.”
China’s two-month lockdown “was enormously successful in suppressing transmission,” note the authors. “The COVID-19 reproduction number (R0) – the average number of people infected by each infected person – fell from 2.35 before the restrictions to 1.05 soon after.”
Many states implemented physical distancing policies several weeks ago. The authors calculate that a “45-day stay-at-home policy starting April 5 would be roughly equivalent in length to the Chinese lockdown.” Forty-five days from April 5 is May 20.
South Korea averaged only 730 new cases per day or 18 new cases per million people at the peak of virus transmission. These low levels of incidence allowed South Korea to control transmission through aggressive tracing and isolation of COVID-19 positive patients and family members without locking down society, the report states.
New case identification rates in the United States are significantly higher. Average daily new cases in the United States over the past week were about 29,000 or 89 per million people, up from 25,000 or about 76 per million people in early April, when the report was published.
“National and state stay-at-home policies must remain in place until these levels are brought down to South Korean levels and we can determine where emerging outbreaks are through testing,” the authors conclude.
- Significantly increase testing capacity to South Korean levels so that every person with a fever and every household member of a COVID-19 identified case are able to be tested.
South Korea adopted an aggressive testing program within several weeks of identifying the presence of coronavirus in the country in late January. South Korea created screening clinics and drive-through centers to minimize the risk of infection spreading. The report states that South Korea had tested about 8,000 per million people (or 0.8% of total population) through late March.
The United States cumulative testing rate is less than half that of South Korea, resulting in a larger number of undiagnosed cases and aiding a higher rate of virus transmission.
Increasing testing capacity to South Korean levels would require an additional 2.6 million tests. The authors conclude that this looks achievable during the next one to two months, given Abbot Laboratories’ recent announcement of the development of a rapid coronavirus diagnostic test. Abbot Laboratories is currently manufacturing 50,000 ID NOW rapid tests per day.
- Adopt surveillance testing in every county to identify the presence of the virus in areas not currently reporting cases to prevent potential outbreaks.
The Seattle Coronavirus Assessment Network (SCAN), a joint effort of the public health departments of Greater Seattle and King County, Washington, is sending swab kits to a sample of demographically representative households. The authors explain that sampling ensures that asymptomatic cases are identified and can determine when transmission in a community has ceased or greatly reduced, so that restrictions can be eased. The report recommends that this sampling should be replicated by public health departments across the country.
The report also notes the potential of serological tests to help determine the spread of infection in communities. Serological tests detect antibodies the immune system produces in response to infection and could also potentially be used to prove immunity. The authors cite a serological study currently underway at the Helmholz Centre for Infection Research in Germany to study the extent of antibodies in the general population and to help develop precise tests.
- Increase production of personal protective equipment to shield front-line workers.
The report makes the important point that testing cannot be significantly expanded if healthcare workers, which may include thousands of volunteers, do not have adequate personal protective equipment (PPE). The authors cite a U.S. Department of Health and Human Services estimate that 300 million N95 respirator masks will be needed for workers.
- Use cell phone technology to speed up contact tracing and alert the public to the location of COVID-19 cases.
Instantaneous contact tracing – using mobile telecommunications infrastructure to identify and quickly notify through text messaging, people who have been in close proximity to a person who has tested positive to COVID-19 – has been critical to the success of South Korea and Singapore in reducing the spread of the virus, the authors conclude.
The report cites research by the University of Oxford which estimates that instantaneous contact tracing can help reduce the reproductive rate (R0) to less than 1.0.
The report suggests implementing a number of safeguards to protect the privacy of individuals and ensure data collected is secure, used responsibly by public health officials and deleted when no longer required.
- Isolate confirmed and suspected cases
The authors recommend that state governments set up temporary residential centers to isolate confirmed and suspected COVID-19 cases on a voluntary basis. The report notes South Korea’s example of establishing “living and treatment support centers” as aiding compliance.
The report also suggests providing hotel rooms or other individual lodging options for front-line healthcare workers to minimize transmission to family members.
- Prohibit non-essential travel during stay-at-home time periods and restrict mass transit.
The authors suggest state and local governments use “aggregated, anonymized cellular data” to assess compliance with stay-at-home orders and determine if enforcement measures are necessary to enforce orders.
The report also recommends: having transportation workers use N95 respirators and other protective gear and receive paid sick leave; requiring daily sanitization of mass transit vehicles and stations; and restricting the number of passengers on buses and trains.
- Establish guidelines for use of face masks until herd immunity is achieved.
Supplies of N95 respirator and surgical masks are limited, and current stock levels must be reserved for healthcare workers. The authors address the question: “Should the general public use homemade cloth masks?”
The report cites two small sample studies suggesting that there is some evidence that homemade cloth masks offer some protection against the coronavirus, with one study finding that particle concentration was 2.4 times greater outside a tea-cloth mask than inside the mask.
The authors recommend that the government issue guidelines on how to make and use cloth masks.
- Targeted, gradual lifting of restrictions
The report concludes by recommending a targeted, gradual lifting of restrictions by states and coordination by states that are ”integrated regionally” such as New York, New Jersey and Connecticut, only after the following criteria are met:
- State transmission levels have been reduced to South Korean levels of about 20 new cases per million people per day, and the number of new cases is declining
- Sufficient COVID-19 diagnostic tests are available for everyone who has a fever and every member of a household of a positive case
- Instantaneous contact tracing has been implemented
- Every front-line health worker has access to PPE
- A surveillance testing system has been established
Even after states lift a stay-at-home order, some social distancing restrictions and health and transit worker protections should be maintained until herd immunity has been achieved through mass vaccination the authors conclude.
The report was written by Zeke Emanuel (senior fellow), Neera Tanden (president and CEO), Topher Spiro (vice president for Health Policy and senior fellow for Economic Policy), Adam Conner (vice president for Technology Policy), Kevin DeGood (director of Infrastructure Policy), Erin Simpson (associate director of Technology Policy), Nicole Rapfogel (research assistant for Health Policy), and Maura Calsyn (managing director of Health Policy) and published on April 3, 2020.