Flattening the curve is just the beginning of a long, tedious process to reopening the world after the coronavirus pandemic
Updated Apr 12, 9:36 AM; Posted Apr 12, 8:00 AM
By Cory Shaffer, cleveland.com
CLEVELAND, Ohio — Gov. Mike DeWine on Thursday said that Ohio leaders are building a “sophisticated” plan to slowly begin to re-open Ohio once officials are confident they have contained the spread of the novel coronavirus.
DeWine cautioned, as a group of demonstrators outside the Statehouse demanded him to “open Ohio” and lift public health orders credited with slowing the virus’ spread, that the process to return to anything close to normal is going to be a very gradual one.
“We’re not going to turn the switch on, and everything goes back to the way it was,” he said.
DeWine said he hoped to be able to unveil the plan next week. Still, those looking for a preview may be able to look to a recently published paper billed as a road map for states to begin lifting stay-at-home orders that have shuttered businesses and devastated parts of the economy.
The paper, released through the conservative American Enterprise Institute, is authored by a group of experts in public health, epidemiology and economics, including former FDA Director Scott Gottlieb.
It echoes sentiments that DeWine and Health Director Amy Acton have stressed for days and continued to stress on Thursday. Flattening the curve is just the beginning of a tedious process that hinges on the ramping up of available testing and medical equipment, the ability to trace and test every person who came into contact with someone who tested positive and the development of a successful vaccine to immunize the country.
The paper, titled “National Coronavirus Response: A Road Map to Reopening,” breaks down the response into four phases: slowing the spread and increasing medical capacity to handle an outbreak, gradually lifting restrictions while developing medication and vaccines for the most vulnerable populations, scaling up for mass vaccinations and fully lifting restrictions, and finally, putting in a framework to prevent the next outbreak.
This paper and others that have attempted to answer the question of what it will take to defeat the pandemic depend on deft leadership and competence from those in statehouses and Washington D.C., and on a public will to keep heeding orders that have upended their lives and the economy.
The paper does not provide a timetable for how long each phase may take to complete. But many experts have said a successful vaccine will not likely hit the market until 2021, meaning that life will continue with at least some restrictions for several more months.
Phase I: ‘Flatten the curve’ and ‘build capacity.’
The “flattening the curve” phase is what Ohio and other states have been doing for the last month. It includes the most dramatic measures of any of the stages. The measures should sound familiar to Ohioans by now: stay-at-home orders, closing schools, restaurants and non-essential businesses. These are all measures that are necessary to slow the virus’ from spreading among the population, the paper says.
At the same time, the state and health care communities must ramp up available bed space and their ability to test people who are already sick with COVID-19 symptoms and quickly determine whether they have the virus, the paper said. Those hospitalized with the most severe symptoms, as well as frontline healthcare workers, first responders and other public-facing and emergency workers, should get priority to the available tests at first. Anyone in close contact with someone with the virus should also get tested in this phase.
States should also increase access to personal protective equipment like N95 masks, the paper says.
Even with that increased capacity to treat cases coinciding with a sustained reduction, experts warn that a move toward less restrictive physical distancing measures could lead to a second spike. That’s why the final, and maybe most challenging, to step in this phase is a dramatic increase of public health infrastructure that expands rapid disease-tracking and quarantine measures to isolate people who fall ill and to act swiftly to avoid potential becoming hotspots.
This would require building up a high-performance disease surveillance machine, made up of widespread testing and fast reporting mechanisms to allow officials to keep an eye on new cases as they pop up, and isolate those people immediately. The paper also suggests providing free rooms for people to quarantine in, through FEMA — for example, someone who lives in a large household who doesn’t want to quarantine with other family members and risk infecting them could live in a repurposed hotel room for 14 days instead. In Ohio, hotels have already offered up their empty rooms to hospitals, homeless shelters and frontline workers.
The paper says that hospitals should have five to seven ICU beds per 10,000 adults in the region they serve. They should have the same number of ventilators and 30 acute care beds available for every 10,000 people. Also, the paper suggests a nationwide ability to test 750,000 people per week.
Using Ohio’s estimated 2020 population of 11.75 million people, the state would need between 5,875 to 8,225 ICU beds and ventilators, and 35,350 acute care beds under the paper’s suggestion. The state’s health department has not released the number of ventilators. Acton said in late March that Ohio had 3,600 intensive care hospital beds. Of those, 2,300 were in use, and 1,300 were available at the time.
Acton said that the success of Ohio’s social distancing measures has knocked down the state’s peak projections of new COVID-19 infections from 10,000 per day to just over 1,600 per day.
Both Acton and DeWine said Friday that it’s not time to declare victory. The paper agrees.
A state is ready to move on from this phase when it sees a sustained reduction in new cases for at least 14 days when three things happen. First, hospitals are safely able to treat all patients without resorting to crisis standards of care. Second, everyone with COVID-19 symptoms can get tested. Third, the state can monitor every person who tested positive for the disease and their contacts.
Phase II: Light at the end of the tunnel and preventing a second spike
There will come a time when states will have the confidence that hospitals will not get overwhelmed with new patients, and there are enough tests and tracking to identify and monitor new cases. Only then is it safe to gradually lift some of the restrictions in place, the paper says.
Healthy people will be able to resume certain activities but will be encouraged to continue to wear non-medical face masks and practice social distancing when possible. People who are in high-risk categories like those over 60 or who have underlying health problems should continue to avoid going out into the community as much as possible.
This phase would ease the burden people holed up for months and millions who have been out of work. It also buys time for the medical community to begin to develop drugs to treat people suffering from the most illnesses, and vaccines to prevent people from catching it in the first place.
The paper cautions the moves taken here should be tepid and says people should expect a reversion to additional restrictions if there is a sign the virus is coming back before a successful vaccine become available.
This is the time when the state would be most susceptible to a second surge when people begin mingling again.
The paper says to avoid that, testing measures developed in the first phase must continue. The government must be able to rapidly test anyone showing symptoms, as well as every person in which they came into close contact. Those who test positive should undergo 14 days of isolation.
The paper says states should carefully consider which restrictions to lift first, and do so one at a time. They must allow enough time between lifting each measure to track its effect on the number of cases and make sure there are no new outbreaks.
Governments should still encourage people to take every measure possible to avoid unnecessary trips into the public and to continue to wear masks. They should also continue limits on gatherings of 50 people or less. Businesses that can allow their employees to work from home should continue to do so, and schoolhouses, daycare centers and high-density workplaces should maintain social-distancing practices as children and workers return to them. Shared surfaces should undergo routine sanitization and frequent deep cleanings, the paper says.
Nursing homes and other long-term care facilities should remain vigilant in monitoring and preventing the virus from taking hold, including continuing to limit visitors.
This phase also suggests that the government use serology tests to determine which people who have recovered from COVID-19 have developed the antibodies that give them the virus and allow them to return to work, or even serve in frontline healthcare workers or in positions who work with the elderly.
Once a vaccine developed and FDA-approved, those who are at the most severe risk of infection should get priority to prevent as many hospitalizations as possible. Once there are enough doses available to vaccinate the broader population, then its time to move to the third phase.
Phase III: Treatment and vaccine developed, restrictions lifted
If the second phase is the light at the end of the tunnel, this is the end of the tunnel that brings the sigh of relief and the ringing of the victory bell.
It’s when at-risk populations receive vaccinations, medications to cure symptoms in less-serious cases and testing and surveillance methods remain available to identify new cases to squash any potential spreading. All restrictions are lifted.
Once researchers develop a vaccine, the paper suggests The Public Health Emergency Medical Countermeasures should work with pharmaceutical companies and other private companies to devise a plan to handle the massive demand to manufacture the drug at scale quickly.
Then the CDC and state and local health departments have to come up with a mass-vaccination plan to determine where to administer the vaccines and who will give them. The government will also have to collect data for vaccination rates and adverse side effects.
Phase IV: Flattening the next curve
The coronavirus exposed massive gaps in the U.S. healthcare system’s ability to respond to a pandemic, but it won’t be the last pandemic, the paper says. Once COVID-19 is in the rearview mirror, the paper says it’s time to rebuild a more robust pandemic response to prevent the next public health crisis from crippling the country.
This includes keeping long-term the increased ICU and hospital bed capacity, expanding the supply chain of personal protective equipment and developing measures for primary care doctors to easily screen and test for new infections to identify early cases, the paper says.
The paper also suggests creating a national infectious disease forecasting center, similar to the National Weather Service. Instead of forecasting weather and major storms, it would use disease modeling to forecast outbreaks and inform public decision making.