COVID-19 is a grave pandemic, the worst we have seen since the 1918 flu pandemic. Its virus is not only harming and killing hundreds of thousands of us, but it is also creating despair and poverty. Its economic and mental health harms are incalculable. As a nation it is putting us more deeply in debt, to be repaid by several generations to come who will have a reduced living standard. Unemployment levels surpass those of the Great Depression. I have chosen not to summarize the harms but to ask what we can do to vanquish this invisible scourge over the next year. Our understanding of the disease and its multiple sector consequences grow daily. So, consider that a version of this short report could be different even a few days from now.  

Treatment and prevention

The scientific situation regarding COVID-19 is very fluid, with pharmaceutical companies testing every potential treatment that could possibly affect the course and/or severity of the disease. At this point, remdesivir is the only anti-viral medication with some (early unrandomized) trials reporting even limited positive effects. However, these trials have been conducted on a small number of patients. Other remdesivir trials show no significant benefits. Finding an effective drug therapy would be an immediate game-changer. 

On the prevention front, there are a plethora of vaccine trials underway and it is very likely that one or more of these vaccines will be chosen for wide-scale manufacturing. In reality, however, the delivery of a vaccine to medical care providers is not expected until the second quarter of 2021. Some epidemiologists mention the possibility that the virus could mutate into a less lethal form, but that hope should not be the basis for planning.
The current shortage of Personal Protective Equipment (PPE) and the lack of availability of high-quality testing equipment will continue for some months. Since most disposable PPE (gowns, gloves and masks) and a significant amount of test equipment and supplies come from China, the negative statements from Washington about China’s role in this pandemic could affect the supply chain in unpredictable ways. It is likely that there will be enough ventilators for the U.S. and other high-income countries over the next several months but demand could exceed supply if there is a strong second wave of the disease.

We are currently seeing a declining number of cases (an early indicator) and deaths (a trailing indicator) in New York and some other hard-hit states, cities and counties. However, the numbers are still on the upswing in some cities (Boston and Los Angeles are examples), adjacent counties and rural areas. Even more troubling is the potential of the second wave of COVID-19 starting in the Fall at about the same time the annual flu outbreak takes hold. Together those two diseases could severely strain our medical care system, especially acute care hospitals. 

The results from early studies of the disease show the risk of a COVID-19 infection is severe enough to cause death rises sharply with every decade of age. One frequently cited study found death rates ranging from 3 percent for people in their 20s to 7.8 percent in those 80 and over. Unlike flu, children and young adults very rarely succumb to this disease.

An unexpected epidemiologic finding, based on antibody tests of prior exposure, is the very large number of inapparent infections with no symptoms or symptoms so mild as to escape notice. These inapparent infections appear to be much more common than the more severe cases with the classic symptoms of fever, cough and difficulty breathing.

However, we do not yet know how protective these inapparent infections are in building immunity to prevent or attenuate future infections. It is likely that the degree and length of protection are less in that group and reinfections may occur within a yet to be determined short time period. To accurately answer this question, we need large scale epidemiologic studies that follow those with antibodies to see how many become reinfected over time. 

Further complicating the options for prevention of new cases is that some patients may be shedding the virus well after their symptoms cease and that, based on testing for the presence of the virus, some patients who tested negative after their infection subsequently tested positive, and thus were able to pass the infection to others.

Containment options

Going forward, expect disagreements between state and local officials because the disease frequency will be different in different parts of the state. A governor is likely to push for a unified full state approach while local officials in jurisdictions with very low (or very high) number of cases may want greater (or lesser) freedoms for their area.

In all jurisdictions, however, the priority for protection should be directed toward older adults and people with chronic illnesses such as lung, kidney or cardiovascular disease, diabetes or reduced immunologic function.

One illustrative scenario for the loosening of containment rules and recommendations is as follows: 

1. Continue to require sheltering in place until the jurisdiction meets the criteria for relaxing restrictions. Criteria could be low levels of infection, declining infection rates in higher rate areas, or a combination of these two. 

2. Slowly decrease restrictions but announce that they are temporary, and subject to reinstatement if the situation worsens. Plan for and broadly communicate that one size doesn’t fit all. For example, current restrictions could be maintained or at least strongly recommended for elder adults or younger individuals with chronic conditions while not for the rest of the population.

3. Augment the number of public health “detectives” to perform contact tracing when the rate of new infections sufficiently declines to make this approach realistic. These workers would isolate the newly infected individual, trace their contacts and require that these contacts are quarantining for two weeks after their contact with the newly infected person. They would also be essential to support the large studies required to answer fundamental questions about disease transmission, differential susceptibility, and risk of recurrence. The additional workforce needed for these efforts to accomplish can come from other public health staff or from outside; for example, clinical staff from local hospitals, social workers or others with related skills. Sufficient training will be essential as will an effective information system that captures and analyzes consistent data from all jurisdictions.

4. Assuming that almost all jurisdictions have allowed grocery stores, pharmacies, and restaurants only serving take out to open, a next step could be reopening parks, beaches and trails, but with monitoring to limit the number of motor vehicles and/or people. Requirements for masking and physical distancing would remain.

5. A logical further step would be the reopening of non-essential stores, factories, and retail outlets but with continued distancing and masking requirements. 

6. The opening of schools could proceed in steps starting with younger students, including pre-school. For example, K through 9 could be reopened first since younger children are more dependent and need a constant adult presence at home. This would release a significant segment of the workforce, facilitating the resumption of commerce. Platooning children to facilitate distancing is another potential option but parents will need to be informed that no school reopening approach, with the exception of exclusive distance learning, will eliminate all risk. 

7. Another step would be to allow those who work in offices to return but strongly urge those who have been able to efficiently work from home to remain off-site until that jurisdiction’s case rate is very low.

8. More problematic regarding infection risk is allowing table service restaurants to reopen. What should be part of a reopening plan is stringent requirements for physical distancing, masking and hygiene for patrons and staff.

9.  For all venues such as schools, worksites, retailers, and meetings, every person should have their temperature checked before entry and anyone with a temperature over 100 degrees should be referred to their usual source of primary care.

10.  Health care sites will need to satisfy patients that their office, surgi-center, or facility is safe. We need metrics to classify any health care delivery site as “safe” and that may require extensive follow-up testing of a cadre of patients and an external quality assurance organization to certify safety.

11. Prepare the public for an unprecedented mass vaccination program, stressing its critical benefits for individuals, families and communities. Engage the best behavioral change and both mass and social media to develop compelling messaging. Have well-respected celebrities with broad appeal across the political spectrum be spokespeople for the campaign.

12. The last restriction to ease should be the size of groups that can physically assemble. That could start at 10 or 15 and progressively increase based on a number of new cases and contact tracing results, but would not allow spectator sporting events, concerts and other large assemblages until herd immunity has been achieved based on antibody testing and vaccination coverage. To achieve herd immunity at least 70 percent of the populations must have antibodies to the disease-causing virus. 

More issues to consider

What do about nursing home residents? Given the high rate of infections in staff and residents could family members or friends take those who test negative into their homes for a defined period and receive the same funding as the nursing home would have received? This is worth exploring with funding sources, especially Medicaid (MediCal) but also private insurers with this benefit.

What are the criteria for re-establishing previously eliminated or reduced COVID-19 based constraints? These need to be considered soon. It may be useful to bring together a small group of state and local public health and medical leaders to discuss this and make recommendations to the elected politicians.

Another factor that will influence the roll-out of relaxing rules and recommendations is insurance. There are currently disagreements about whether the effects of this pandemic should be covered under business interruption insurance. However, the biggest insurance issue may be a liability. One of many possible questions is: If a child is mandated to attend a reopened school and subsequently gets infected from the student sitting next to her and dies from that infection, is the school liable? Legislation may be required to resolve the major liability questions.  

The most important issue

Most critical is to not be ill-prepared for an epidemic with a novel pathogen and not mismanage the response. Thousands of lost lives could have been avoided by mounting a whole of government approach in a timely manner. It is tragic that our delayed, uncoordinated response provides so many examples of what not do to, for example, not marshaling resources, being untruthful in communicating with the public and not accepting assistance such as accurate tests from WHO and from other nations.

Based on experiences with and lessons from other epidemics such as H1N1, Zika, SARS, MERS, and Ebola we know what to do. What we need is government support to help us do it. An indispensable step in that direction is funding a strong nationwide surveillance system to identify new cases especially after the current surge is controlled. Remember, in 1918 the worst wave of the pandemic was after it appeared to be over.

Jonathan Fielding, M.D., is a professor of public health and pediatrics at the University of California, Los Angeles.