Question: What are the hard and fast requirements for reopening society and the economy? Is chatter about reopening premature? What will reopening look like across the US? What will have to be in place and what will be required of individuals?
Answer: So many good questions that so many people are trying to answer. I think we should be talking openly and honestly about all of these things and we should be working on evidence-informed plans for reopening now! Actual reopening now would be far too premature, but planning for it now is a necessity. To dive into your other questions, let’s first remember why we are social distancing, then let’s talk about what’s required to ease up on social distancing, and finally what reopening might look like.
Why Social Distance?: The big goals of social distancing are:
- To curb and ideally stop community transmission (e.g. stop the spread of infection from unknown exposure);
- To get our health systems prepared (e.g. needed supplies, equipment, and personnel in place);
- To get our public health system working at massive scale (e.g. ready for widespread testing, contact tracing, suspected case isolation, surveillance)
How do we know when we can ease social distancing?: The short answer to this question is that we ease social distancing when the above three goals are achieved. Ideally, Goals 2 and 3 will be achieved at national scale while Goal 1 will be achieved on a community-by-community basis. If you’re curious about how we might measure success in achieving goals 1, 2, and 3, see the longer subsection below. Ultimately, we’ll be past social distancing when we have a safe and effective vaccine that is rolled out across the population. An effective and widely available treatment will also help towards reopening.
What might reopening look like?: The goal of reopening is to get us back to functioning while stopping community transmission from starting back up again. To do this, we need to: a) only start reopening after we’ve achieved the three goals listed above; 2) start reopening on a slow basis so that our public health systems can quickly identify new cases, identify all contacts of those new cases, and ensure that these folks are self isolating; 3) as things improve (we keep new cases and community transmission abated), we expand reopening. Note: moving from social distancing to expanded reopening will not happen on a national-level — we’re just too big — and will instead happen at state and local levels. Additionally, we’ll likely find ourselves in a dance — moving between expanding and constricting reopening and possibly even an/other period(s) of social distancing.
What does success for Goals 1, 2, and 3 look like? (a non-exhaustive list of several key indicators)
- To assess whether we’ve curbed/stopped community transmission, we’d expect to see:
- Decrease in number of new cases: This would require wide-scale testing, which we do not have; In New York, where we do have much wider scale testing than elsewhere in the country, we are seeing a curb in community transmission with the number of new cases being quite similar each day.
- Decrease in the proportion of positive tests: If we keep testing criteria as stringent as it currently is in most places (based on CDC guidelines), then we might want to look at the proportion of tests that have positive results. We’d want to see that proportion decline over time; In New York, even as testing has expanded, we still see that about 40% of tests are positive.
- Decrease in number of new COVID hospitalizations and daily total of hospitalized COVID patients: In absence of testing data, we would look to hospitalization data; In New York, we’re seeing that social distancing successfully curbed growth in hospitalizations, but we’re still seeing ~2,000 new COVID hospitalizations a day and about 18,000 patients hospitalized each day, which is a plateau.
- Given the above, I’d argue that New York has curbed community transmission, but has not stopped community transmission.
2. To assess whether our hospitals are prepared, we’d expect to see:
- Supply chains effectively working with systems in place to address supply shortages (e.g. in context of limitation, systems effectively and transparently share resources) — Right time, right place, right quantity, right quality supply chain performance measures could be used. In absence of these measures, we’d base success on hospital and gubernatorial reports.
3. To assess whether our public health system is prepared, we’d expect to see:
- A higher per capita testing rate, representing widespread testing using more relaxed criteria than CDC’s current criteria — along the lines of South Korea or even Italy (see chart below; much of the rise in US per capita testing is thanks to New York). As I mentioned in our Q&A of 4/10, epidemiologists suggest that testing should be so widespread that only 1 of every 10 tests is positive.
- Contact tracing in place to find all known contacts of each positive case and ask those contacts to self isolate. This would be based on number of workers hired into these roles. Estimates of need range from 100,000 to >300,000.
- Existing surveillance systems providing real-time data on coronavirus incidence and spread.
