It seems that the current thinking in the Trump Administration is to try to relax physical distancing on May 1st and declare victory.
AG Bill Barr, on Fox News, refers to current restrictions as “draconian measures” and says at end of April, he thinks we should “allow people to adapt more than we have, & not just tell people to go home and hide under their bed.”
— Matt Zapotosky (@mattzap) April 9, 2020
That won’t work. The roadmap to re-opening that does not lead to overwhelmed hospitals in two or three weeks after the end of steps that have successfullly flattened the curve involves significant planning and benchmark based actions.
My boss, Dr. Mark McClellan and others have been writing and publishing a series of white papers on what needs to happen as a roadmap to re-open. The overarching strategy is outlined in a March 29, 2020 paper. It splits the pathway into four phases:
Phase 1: Use Physical Distancing and public health measures to flatten the curve and slow the spread.
Phase 2: Gradual state by state or in-state region by in-state region re-opening
Phase 3: Immune protection and return to normality
Phase 4: Prepare for the next pandemic
Right now we are in Phase 1. There are several major requirements of moving from Phase 1 to Phase 2.
Trigger to Move to Phase II. To guard against the risk that large outbreaks or epidemic spread could reignite once we lift our initial efforts to “slow the
spread,” the trigger for a move to Phase II should be when a state reports a sustained reduction in cases for at least 14 days (i.e., one incubation period); and local hospitals are safely able to treat all patients requiring hospitalization without resorting to crisis standards of care4; and the capacity exists in the state to test all people with COVID-19 symptoms, along with state capacity to conduct active monitoring of all confirmed cases and their contacts
This means exponential community spread has to be broken. The reproductive number has to be brought and kept under control and preferably under 1 for several weeks in a state. Part of breaking community transmission is that there must be sufficient testing of high enough specificity and sensitivity widely available in all areas with the ability to rapidly flex testing to regions of high need. We are not close to that yet. We are getting closer to the raw numbers of tests but deployment is still a mess. Another requirement of moving from Phase 1 to Phase 2 is that the hospitals need to be able to withstand local surges from local, contained outbreaks. This means sufficient beds, sufficient ventilators, sufficient staff and sufficient PPE among many other criteria. Again, no state will be there by the end of next week much less the entire country.
Phase 2 requires both massive public health surveillance and the ability and willingness to quickly smother new hot spots of localized infections. This is the test, contact-trace and quarantine model that South Korea has been using. As soon as anyone is suspected of being infected, everyone that they have interacted with is identified and placed into quarantine long enough for an infection to either develop or for a high degree of confidence to emerge that the contacts are not asymptomatic and infectious. This infrastructure will dwarf typical public health capacity as this part of the playbook is really effective when case counts measure in the single or double digits but gets quickly overwhelmed. If Phase 2 steps fail locally, a region or a state can toggle back to Phase 1 to re-break community spread.
Phase 3 is when there is herd immunity through the combination of serological testing to identify individuals who have been infected and recovered and the deployment of an effective vaccine to wide swathes of the population. It is currently unlikely that there is a huge swathe of individuals who have developped immunity to asymptomatic COVID19 at this time.
There is a roadmap to re-open. It is a deliberate set of strategies that allow for triggering actions forwards and backwards as circumstances dictate. It is not a fast process and even as regions move from Phase 1 to Phase 2 or from Phase 2 to Phase 3, significant changes to the social sphere will happen compared to January 1, 2020 expectations.
Moving to a Phase 2 or Phase 3 world on May 1st will dictate that we’re back in a Phase 1 world by Memorial Day as several colleagues have looked at that scenario in North Carolina. The risks of re-opening a week or a month too early versus re-opening a week or a month too late are asymmetrical with far more risk accruing to re-opening and relaxing physical distancing requirements early rather than late.