Getting past the coronavirus: ‘A road map to reopening’ by the American Enterprise Institute

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Credit: Jay L. Clendenin / Los Angeles Times

Executive Summary

This report provides a road map for navigating through the current COVID-19 pandemic in the United States. It outlines specific directions for adapting our public-health strategy as we limit the epidemic spread of COVID-19 and are able to transition to new tools and approaches to prevent further spread of the disease. We outline the steps that can be taken as epidemic transmission is brought under control in different regions. These steps can transition to tools and approaches that target those with infection rather than mitigation tactics that target entire populations in regions where transmission is widespread and not controlled. We suggest measurable milestones for identifying when we can make these transitions and start reopening America for businesses and families.

[Editor’s note: Scott Gottlieb is a former commissioner of the US Food and Drug Administration.]

In each phase, we outline the steps that the federal government, working with the states and public-health and health care partners, should take to inform the response. This will take time, but planning for each phase should begin now so the infrastructure is in place when it is time to transition.

[Download the full report here.]

The specific milestones and markers included in the report for transitioning our responses are judgments based on our current understanding, with the goal of facilitating an effective path forward. The epidemic is evolving rapidly, and our understanding of best responses will evolve as well. The broad set of tasks described here requires and will receive high-level, ongoing attention, and it should be updated and refined as additional evidence, context, and insights about the epidemic become available.

To gradually move away from a reliance on physical distancing as our primary tool for controlling future spread, we need:

  1. Better data to identify areas of spread and the rate of exposure and immunity in the population;
  2. Improvements in state and local health care system capabilities, public-health infrastructure for early outbreak identification, case containment, and adequate medical supplies; and
  3. Therapeutic, prophylactic, and preventive treatments and better-informed medical interventions that give us the tools to protect the most vulnerable people and help rescue those who may become very sick.

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Our stepwise approach depends on our ability to aggregate and analyze data in real time. To strengthen our public-health surveillance system to account for the unprecedented spread of COVID-19, we need to harness the power of technology and drive additional resources to our state and local public-health departments, which are on the front lines of case identification and contact tracing. Finally, we must expand our investments in pharmaceutical research and development into COVID-19 and promote the rapid deployment of effective diagnostics, therapies, and eventually a vaccine.

Slow the Spread in Phase I. This is the current phase of response. The COVID-19 epidemic in the United States is growing, with community transmission occurring in every state. To slow the spread in this period,1 schools are closed across the country, workers are being asked to do their jobs from home when possible, community gathering spaces such as malls and gyms are closed, and restaurants are being asked to limit their services. These measures will need to be in place in each state until transmission has measurably slowed down and health infrastructure can be scaled up to safely manage the outbreak and care for the sick.

State-by-State Reopening in Phase II. Individual states can move to Phase II when they are able to safely diagnose, treat, and isolate COVID-19 cases and their contacts. During this phase, schools and businesses can reopen, and much of normal life can begin to resume in a phased approach. However, some physical distancing measures and limitations on gatherings will still need to be in place to prevent transmission from accelerating again. For older adults (those over age 60), those with underlying health conditions, and other populations at heightened risk from COVID-19, continuing to limit time in the community will be important.

Public hygiene will be sharply improved, and deep cleanings on shared spaces should become more routine. Shared surfaces will be more frequently sanitized, among other measures. In addition to case-based interventions that more actively identify and isolate people with the disease and their contacts, the public will initially be asked to limit gatherings, and people will initially be asked to wear fabric nonmedical face masks while in the community to reduce their risk of asymptomatic spread. Those who are sick will be asked to stay home and seek testing for COVID-19. Testing should become more widespread and routine as point-of-care diagnostics are fully deployed in doctors’ offices.

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While we focus on state-by-state reopening of activities in a responsible manner and based on surveillance data, we note that states may move forward at a county or regional level if these conditions vary within the state and that coordination on reopening among states that share metropolitan regions will be necessary.

Establish Immune Protection and Lift Physical Distancing During Phase III. Physical distancing restrictions and other Phase II measures can be lifted when safe and effective tools for mitigating the risk of COVID-19 are available, including broad surveillance, therapeutics that can rescue patients with significant disease or prevent serious illness in those most at risk, or a safe and effective vaccine.

Rebuild Our Readiness for the Next Pandemic in Phase IV. After we successfully defeat COVID-19, we must ensure that America is never again unprepared to face a new infectious disease threat. This will require investment into research and development initiatives, expansion of public-health and health care infrastructure and workforce, and clear governance structures to execute strong preparedness plans. Properly implemented, the steps described here also provide the foundation for containing the damage that future pathogens may cause.

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Phase I: Slow the Spread

The goal of Phase I is to save lives by:

  1. Slowing the transmission of SARS-CoV-2 across the United States by reducing the effective reproduction number of infections,
  2. Increasing testing capacity to accommodate the ability to test everyone with symptoms and their close contacts, and
  3. Ensuring the health care system has the capacity to safely treat both COVID-19 patients and others requiring care.

Phase II: Reopen, State by State

In Phase II, the majority of schools, universities, and businesses can reopen. Teleworking should continue where convenient; social gatherings should continue to be limited to fewer than 50 people wherever possible. Other local restrictions should be considered, such as those that limit people from congregating in close proximity.

Phase III: Establish Protection Then Lift All Restrictions

Once a robust surveillance sentinel system is in place, coupled with widespread point-of-care testing and a robust ability to implement tracing, isolation, and quarantines—and this is supported by the availability of therapeutics that can help mitigate the risk of spread or reduce serious outcomes in those with infections—or alternatively a vaccine has been developed and tested for safety and efficacy, we can enter Phase III. The availability of these technologies (and eventually a safe and effective vaccine) will have economic and social benefits, in addition to health benefits.

Phase III: Establish Protection Then Lift All Restrictions

Once a robust surveillance sentinel system is in place, coupled with widespread point-of-care testing and a robust ability to implement tracing, isolation, and quarantines—and this is supported by the availability of therapeutics that can help mitigate the risk of spread or reduce serious outcomes in those with infections—or alternatively a vaccine has been developed and tested for safety and efficacy, we can enter Phase III. The availability of these technologies (and eventually a safe and effective vaccine) will have economic and social benefits, in addition to health benefits.

Phase IV: Rebuild Our Readiness for the Next Pandemic

The COVID-19 pandemic has exposed serious gaps in our nation’s pandemic preparedness. COVID-19 will not be the last public-health emergency to threaten American society. We must invest in the scientific, public-health, and medical infrastructure needed to prevent, detect, and respond to the next infectious disease threat.

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