Before COVID-19 was even detected in the United States, Dan Erickson, a former emergency room physician who now co-owns Accelerated Urgent Care in Bakersfield, bought as many tests for the virus as he could. He knew it would be here eventually and wanted to be ready to test those who needed and wanted it.
Dr. Dan Erickson and Dr. Artin Massihi from Accelerated Urgent Care held a news conference April 22 at their Coffee Road facility to talk about coronavirus trends and the impact on the economy.
Alex Horvath / The Californian
Now, after testing thousands of people, he and his business partner, physician Artin Massihi, say they have enough data to draw some conclusions about COVID-19.
Their message: COVID-19 is more ubiquitous and less deadly than we think. It's similar to influenza and we should therefore reopen society and stop treating the situation like the lethal menace it was initially thought to be.
"Two months ago we didn't know this so I'm bringing it to light now," Erickson said Wednesday at a news conference held at his Coffee Road urgent care.
Kern County Public Health Services Spokeswoman Michelle Corson and an epidemiologist contacted by The Californian said they didn't agree with the doctors' recommendation to end social distancing and immediately start reopening society.
"This is a many-headed hydra. It’s really unfortunate to boil this all down to it’s just flu," said Andrew Noymer, associate professor of public health at UC Irvine. "There’s no flu season that looks anything like New York does right now."
'Similar to flu'
Accelerated urgent care has done 5,213 COVID-19 tests at its five Bakersfield locations, Erickson said — which is more than half the 9,197 tests done so far in Kern County. Of those, 340 were positive, according to Erickson.
If that percentage of positive cases were assumed to represent the entire population of Kern County, which is roughly 900,000, it would mean about 58,000 people in Kern have had the virus, far more than the nearly 700 official confirmed, Erickson said.
That many cases would "indicate there is a widespread (COVID-19) infection, similar to flu," Erickson said.
And if we don't shutdown the country for flu, should we keep doing it for coronavirus?
"It’s about looking at trends and saying we’re not seeing what they've been talking about for the past six to eight weeks," said Massihi, referring to predictions that up to 100,000 Americans could die of the virus and hospitals would become swamped with patients. "We’ve crippled the economy. There’s a lot of domestic issues going on. Is social isolation warranted for the healthy?"
Using the same calculation, Erickson estimates 12 percent of the population statewide, or some 4.7 million Californians, have already had COVID-19. With about 1,400 deaths so far in California, that puts the statewide death rate at about .03 percent, he said.
"Does that (low death rate) necessitate sheltering in place? Does that necessitate shutting down medical systems? Does that necessitate being out of work?" Erickson asked.
Nationwide, about 42,000 people have died of coronavirus as of Wednesday. Between 30,000 and 60,000 die of flu annually, Erickson said, citing CDC data.
The secondary effects of the shutdown are considerable, too, he said. They include a dramatic decrease in volumes at hospitals and even Erickson's urgent care practice, where staff are mostly testing patients for COVID-19 these days.
Dan Erickson, a former emergency room physician who co-owns Accelerated Urgent Care in Bakersfield held a news conference at his Coffee Road facility to talk about data available on coronavirus and how he feels it is similar to flu.
Alex Horvath / The Californian
The Californian has reported that hospital volumes are significantly decreased in recent weeks as elective surgeries have been canceled and many people are staying home for fear of contracting COVID-19, which is in turn causing financial strain for healthcare facilities. Erickson wondered what could happen when the economy reopens and people begin flooding into hospitals that have reduced their staffs.
He said local leaders and colleagues of his here and across the country are reporting increased incidents of child molestation and domestic violence while people are at home, and suicides are also spiking. He also noted a contradiction between allowing people to shop at Costco and Home Depot but not allowing them to go to church.
"If you're going to dance on someone's constitutional rights you better have a good reason, you better have a really good reason, not just a theory," he said. "The data is showing us it's time to lift (the stay-at-home orders) so if we don't lift, what is the reason?"
Noymer of UC Irvine disagreed with the doctors' premise that COVID-19 is as widespread as Erickson and Massihi think, saying the idea that nearly 5 million Californians have had the virus is a gross overestimate. The people tested in California were not a random sample; they were mostly people who were symptomatic, Noymer said. Therefore, extrapolating the positive test rate across the entire population of the state is not an accurate way to arrive at how widespread the virus is.
And even if 12 percent of the state has had the virus, that still leaves 88 percent vulnerable to it, Noymer said.
"They’re advancing factual inaccuracies and playing off the esoteric nature of the mortality stats to make a case that the economy should be reopened," Noymer said. "I agree it should be reopened, but it should be opened deliberately, bit by bit, and informed by science. Not informed by a misreading of the mortality."
But people will have different ideas on how to balance the economic costs of trying to stem the pandemic.
"Like many other things in society, we’re going to have to come to a consensus about how we allocate resources," Noymer said.
Corson said she disagreed with any assertion that we should abandon social distancing and stay-at-home orders. The county continues to adhere to Gov. Gavin Newsom's orders in order to mitigate illness and deaths from the virus and the impact it could have on the local healthcare systems, she said.
"We completely understand how eager everyone is to get back to our lives, but right now protecting our health is our number one priority and this is not the time to let up," Corson said. "I want to strongly reiterate this is the time to stay vigilant and stay at home and practice social distancing."
Big Tech is using coronavirus to increase its power - and the US is becoming more like China By Tucker Carlson
Monday night on this show, we played you a clip from a nearly hour-long video produced by two physicians in California, Dr. Dan Erickson and Artin Massihi.
Likely, many of you had already seen it. That video has had more than 5 million views on YouTube. In their presentation, the two doctors presented a flurry of data pointing to what we are currently learning about the coronavirus and how it spreads. They cited pages of government statistics and then interpreted them in light of their own long clinical experience as doctors.
At one point, they noted that the newly adjusted death rate in their state of California, which is much lower than anyone expected it to be, and they asked if government officials there should change their policies based on this new science.
Dr. Dan Erickson: We've seen 1,227 deaths in the state of California with a possible incidence or prevalence of 4.7 million. That means you have a 0.03 chance of dying from COVID-19 in the state of California.
0.03 chance of dying from COVID in the state of California -- is that -- does that necessitate sheltering in place? Does that necessitate shutting down medical systems? Does that necessitate people being out of work?
So, whatever your view of the mass quarantines -- and maybe you're enthusiastically for them -- the questions you just heard are valid questions. In fact, they're critical questions. We should all be asking those questions, including and especially our policymakers.
But as Dr. Erickson pointed out later in the video, dissent of any kind is no longer tolerated in this country. Fact-based honesty, which is the soul of science, is under attack, even in hospitals.
Dr. Erickson described physicians being pressured to classify illnesses and deaths as related to coronavirus, whether they believe that to be true or not.
Erickson: We aren't pressured to test for flu. But ER doctors now, my friends and I talk, saying, you know, it's interesting when I'm writing up my death report, I'm being pressured to add COVID. Why is that? Why are we being pressured to add COVID? To maybe increase the numbers and make it look a little bit worse than it is? I think so.
So, what you just heard -- what Dr. Erickson described -- is called lying, and lying has no place in science, ever. It's scary to think it takes place on a large scale in hospitals. He says it does.
Viewers of Erickson's video were shocked and transfixed by this. They forwarded the video to friends, who forwarded it on to their friends, and suddenly, millions of people who spent the last six weeks on a diet of "Tiger King" and internet memes were watching sober-minded medical researchers reading from charts of statistics. It's hard to recall a science video taking off like this one did.
Not everyone was impressed by it. Some criticized the doctors' policy conclusions, and of course, that's fair. Decent people have different opinions. We're not entirely certain what the perfect response to this pandemic is. Nobody is certain. There's no objective answer at the moment.
At best, we can plod along with open minds and good faith. More informed debate is exactly what we need to make wise decisions going forward.
Unfortunately for all of us, informed debate is exactly what the authorities don't want. They want unquestioned obedience, so they're cracking down on free expression.
Last night, the doctors' video, the one you just saw, was pulled off of YouTube, the largest video hosting site in the world. It wasn't an accident, YouTube admitted doing it. The company cited a violation of "community guidelines" and they did not apologize.
Looking back, when all of this is finally over and it will be, it's likely we'll see this moment -- what YouTube just did -- as a turning point in the way we live in this country, a sharp break with 250 years of law and custom. The two doctors' video was produced by a local television channel in California. It was, in effect, a mainstream news story.
The video was not pornographic. It didn't violate copyright or incite violence or commit libel. It didn't break any law. The only justification for taking it down was that the two physicians on-screen had reached different conclusions from the people currently in charge. It was a form of dissent from orthodoxy.
No wonder our leaders have done such a poor job protecting us from China. They're on the same team.
YouTube and its parent company, Google have now officially banned dissent. The CEO of YouTube admitted that openly.
Susan Wojcicki, CEO of YouTube: But then we also talked about removing information that is problematic. You know, of course, anything that is medically unsubstantiated, so people saying, like, to take Vitamin C, you know, take turmeric, like those all will cure you.
Those are the examples of things that would be a violation of our policy. Anything that would go against World Health Organization recommendations would be a violation of our policy. And so, remove is another really important part of our policy.
Brian Stelter, CNN chief media correspondent: So you're not just putting the truth next to the lie, you're taking the lie down. That's a pretty aggressive approach.
We're removing "anything that would go against World Health Organization recommendations." It'll now be taken off the internet.
Consider that for a minute. As a matter of just science, it's ludicrous. Like everyone else involved in global pandemic policy, the WHO has often been wrong in its recommendations. A lot of people have.
In mid-January, WHO told us that coronavirus could not spread from person-to-person. In March, they told us that face masks didn't work. Those were lies, and they were welcome on Google's platforms.
Doctors who are actually treating patients with the virus, meanwhile, have just been banned. So, no, this is not about science. Censorship never is about science. It's about power. Big Technology companies are using this tragedy to increase their power over the American population. They're working in concert with politicians in order to do it.
Just on Tuesday, Facebook removed an events page for a political protest in Michigan. Gov. Gretchen Whitmer, who runs that state, was no doubt pleased to see it.
Grossly mismanaging an entire state is a lot easier when citizens are not allowed to complain about it, and now they're not. Last week, Facebook founder Mark Zuckerberg explained that protests like these are no longer protected political speech; they are "misinformation."
As we fight this virus, we are becoming far more like the country that spawned it. We're becoming more like China. It's horrifying. And it tells you everything that our professional class enthusiastically welcomes this.
George Stephanopoulos, ABC News host: How do you deal with the fact that Facebook is now being used to organize a lot of these protests to defy social distancing, defy the social distancing guidelines in states? If somebody is trying to organize something like that, that qualifies as harmful information.
Mark Zuckerberg, CEO of Facebook: We do classify that as harmful misinformation, and we take that down.
"Harmful misinformation" -- that is a phrase familiar to anyone who has watched totalitarian regimes in any country. It's now how Mark Zuckerberg describes political opinions he doesn't like.
Our free press exists to push back against obvious abuses of power like this one. It's the reason we have a First Amendment. It's the only reason we have a First Amendment.
But suddenly our media are not concerned about freedom of speech. Reporters applaud our overlords as they punish us for disagreeing. You just saw it in that clip from CNN. That happens every day.
Our media are no longer challenging power, they are colluding with power. And that may be why there's been so little critical coverage of the massive expansion of our surveillance state currently in progress.
In the name of fighting the coronavirus, tech companies are now following you through your cell phone. They're watching you from above with drones. Those sound like paranoid fantasies; they are not. It's happening as we speak.
Needless to say, our politicians approve of this.
Andrea Mitchell, NBC News chief foreign affairs and senior Washington correspondent: How do you feel about the drones?
Sen. Cory Booker, D-N.J.: Look, at this point, we need to save lives and it's really important that in public spaces, people are abiding by the directives.
Yes, we've got to do it.
So, what do we have here? We have Big Tech companies partnering with the government to spy on you without your knowledge. Americans locked in their homes, banned from going to church, placated with sedatives, like weed and beer.
Anyone who speaks up is silenced. Political demonstrations are illegal. Organizers are arrested. Only opinions approved by leaders, many of them unelected, are allowed on information platforms.
Does that sound familiar? It sounds a lot like China.
Of all the many ironies of this moment, so many of them bitter, the hardest to swallow is this one. As we fight this virus, we are becoming far more like the country that spawned it. We're becoming more like China. It's horrifying. And it tells you everything that our professional class enthusiastically welcomes this.
Over the weekend, The Atlantic magazine published an article by two academics calling for an end to freedom of speech in America. Their model for an ideal system? The totalitarian government of China. "In the debate over freedom versus control of the internet, China was largely correct and the U.S. was wrong."
You ought to read the whole thing. Truly, you should. It's the future. We could quote from it for the rest of the show, but we'll give you just one more: "Significant monitoring and speech control are inevitable components of a mature and flourishing internet and governments must play a large role in these practices to ensure that the internet is compatible with society's norms and values."
"Norms and values." Whose norms and values? Well, our leaders' norms and values, of course, but mostly their interests. Those in power are the ones our professional class seeks to protect, not the rest of the country.
Freedom of conscience never endangers the public. It only threatens the powerful. It endangers their control. It hinders their ability to dictate election results, to loot the economy, to make policies based on whim for their own gain.
No wonder our leaders have done such a poor job protecting us from China. They're on the same team.
Adapted from Tucker Carlson's monologue from "Tucker Carlson Tonight" on April 28, 2020.
Local doctors spark widespread debate over virus's death rate, when to reopen By Stacey Shepard
A call by two Bakersfield doctors to reopen the economy and lift social distancing orders caught fire on social media in recent days, drawing a tweet of support from Elon Musk and landing the doctors appearances on Fox News. But their assertions also have drawn strong rebukes from medical and health professionals, and censorship on YouTube.
“These reckless and untested musings do not speak for medical societies and are inconsistent with current science and epidemiology regarding COVID-19,” the American College of Emergency Physicians and the American Academy of Emergency Medicine said in a joint statement issued Monday. “As owners of local urgent care clinics, it appears these two individuals are releasing biased, non-peer reviewed data to advance their personal financial interests without regard for the public’s health.”
In response, one of the doctors, Dan Erickson, of Accelerated Urgent Care in Bakersfield, said in a statement issued Tuesday: “We are not interested in bickering with medical institutions. Accelerated is focused on solutions and caring for our patients with the highest level of compassion and integrity. Accelerated has been a leader in giving testing results to Kern County to help treat and manage Covid 19 illness."
Erickson and Artin Massihi, both licensed California physicians and co-owners of the urgent care practice in Bakersfield, called a news conference last week where they cited their own testing data and state and national figures to argue that the coronavirus is far more widespread than thought and has a low death rate, similar to flu.
The doctors were early to set up a COVID-19 test center in Bakersfield and have now done the majority of testing in Kern County, about 6,000 COVID-19 tests out of more than 10,000 total tests. They report more than 400 positive results out of a total of 856 confirmed cases as of Tuesday.
The doctors’ news conference was livestreamed by local television stations and the video has been viewed millions of times on YouTube and shared widely on social media, attracting both support and criticism.
Local station KERO-TV 23 said Monday that YouTube had removed a video the station posted of the doctors' news conference last week.
A statement from YouTube on KERO's website Tuesday read: “We quickly remove flagged content that violate (sic) our Community Guidelines, including content that explicitly disputes the efficacy of local healthy (sic) authority recommended guidance on social distancing that may lead others to act against that guidance. However, content that provides sufficient educational, documentary, scientific or artistic (EDSA) context is allowed — for example, news coverage of this interview with additional context.”
At issue are both the validity of the doctors’ statistical calculations used to arrive at the low death rate and their conclusion that social distancing and the shutdown order are no longer necessary.
Carl T. Bergstrom, a biology professor at the University of Washington, said on Twitter that the doctors' calculations were not statistically sound and likened it to "estimating the average height of Americans from the players on an NBA court."
Erickson said he arrived at his conclusion about the low death rate by assuming the percentage of positive COVID-19 tests is representative of infection among the general population. In one example last week, he used California’s 12 percent positive test rate to extrapolate that as many as 5 million Californians have had the virus (5 million is 12 percent of the state's population of 40 million). He then calculated a death rate using the number of reported deaths in California — around 1,200 last week — out of the 5 million people who he believes have likely had the virus, coming out with a 0.03 percent death rate, which is similar to the death rate for flu.
"Millions of cases, small amount of death," Erickson said repeatedly in the news conference.
However, that analysis has been called incorrect because of sampling bias, according to UC Irvine associate public health professor Andrew Noymer. Because most people seeking tests for COVID-19 likely had symptoms, the infection rate among those tested will be much higher than among the general population.
Rob Davidson, an emergency physician in rural Michigan and executive director of the Committee to Protect Medicare, called the doctors’ analysis a “ridiculous ‘napkin math’ statistics note.”
In a video posted to Twitter, Davidson said: “Let’s be clear, these gentlemen have nothing to add to the discussion on when we open up and how we open up. We need a national testing strategy. We need to test a million people a day. Then we can safely open up when we see numbers going down for at least two weeks.”
He added, “I’m hoping these guys are done, their 15 minutes of fame are done.”
On “The Ingraham Angle” with Laura Ingraham on Fox News Monday night, Erickson seemed to temper his message somewhat. He did not mention statistical calculations except to say that the positive rate in Kern County based on tests at his center was about 6 percent, which was in line with recent studies out of the University of Southern California and Stanford University suggesting the rate among the general population in those areas was perhaps as much as 4 percent to 5 percent. However, those studies also have drawn criticism.
Asked by Ingraham why he thought their message had attracted so much attention, Massihi said: “There’s folks that are at home, they don’t have a job, they’ve lost their income ... I think folks feel we understand them and we do. We’re advocates for average Americans.”
Erickson told Ingraham he had been studying the approach Sweden has taken to the coronavirus, where leaders have not imposed a lockdown, kids are still in school, and handwashing and some social distancing are recommended but not enforced. Yet the virus has not raged out of control, Erickson said, then suggesting that could be tried in Kern County.
“Our approach would be to take Kern County, get the school systems going and see how the disease progresses,” he said. “Move slowly, open up the restaurants, see how it progresses. Kind of a stepwise approach down the ladder to get us back to open up the country.”
A tweet from the account for Accelerated Urgent Care Tuesday said Erickson would appear again Tuesday night on Fox News @ Night at 8 p.m. with Shannon Bream.
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 approach away from sweeping
mitigation strategies as we limit the epidemic spread of COVID-19, such that we
can transition to new tools and approaches to prevent further spread of the
disease.
The authors outline the steps that can be taken
as epidemic transmission is brought under control in different regions. They
also suggest measurable milestones for identifying when we can make these
transitions and start reopening America for businesses and families.
In each phase, the authors 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.
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.
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.
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:
Better data to identify areas of spread and the
rate of exposure and immunity in the population;
Improvements in state and local health care system
capabilities, public-health infrastructure for early outbreak identification,
case containment, and adequate medical supplies; and
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.
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.
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.
Phase I: Slow the Spread
Goals
The goal of Phase I is to save lives by:
Slowing the transmission of SARS-CoV-2 across
the United States by reducing the effective reproduction number of infections,
Increasing testing capacity to accommodate the
ability to test everyone with symptoms and their close contacts, and
Ensuring the health care system has the capacity
to safely treat both COVID-19 patients and others requiring care.
A successful Phase I will allow for a significant relaxation of physical distancing measures and a progression to Phase II, when more targeted, case-based interventions are possible.
Thresholds for Action
Trigger to Begin to “Slow the Spread.”
The trigger to implement nationwide “slow the spread” measures2 in Phase I is the existence in multiple geographic locations around the country of confirmed cases that cannot be traced back to other known cases (“community spread”).3 This trigger has already been reached in the United States.
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.5
Stay-at-Home Advisories
The trigger for issuing a stay-at-home advisory6 in a US state is when case counts are doubling every three to five days7 (based on the current New York experience) or when state and local officials recommend it based on the local context (for example, growth on track to overwhelm the health system’s capacity).
The trigger for issuing a recommendation to step down from a stay-at-home-advisory back to “slow the spread” is when the number of new cases reported in a state has declined steadily for 14 days (i.e., one incubation period) and the jurisdiction is able to test everyone seeking care for COVID-19 symptoms.
Steps Required in Phase I
Maintain Physical Distancing. Each state must maintain community-level physical distancing measures8 until the threshold for moving to Phase II is met. These Phase I measures include:
Closing community gathering spaces such as
schools, shopping centers, dining areas, museums, and gyms statewide (places
where people congregate indoors);
Promoting telework for nonessential employees statewide;
Urging the public to limit unnecessary
domestic or international travel;
Canceling or postponing meetings and mass
gatherings;
Shutting dining areas but encouraging
restaurants to provide takeout and delivery services if possible;
Issuing stay-at-home advisories in hot spots
where transmission is particularly intense (i.e., when case counts are doubling
in a city or locality every three to
five days); and
Monitoring community adherence to physical
distancing and stay-at-home advisories, adjusting risk messaging as
appropriate, and identifying alternative incentives for compliance if needed.
Increase Diagnostic Testing Capacity and Build Data Infrastructure for Rapid Sharing of Results. Same-day, point-of-care diagnostic testing (widely available in outpatient settings) is crucial for identifying cases, including those with asymptomatic and mild infections. To move from community-wide interventions that focus on large populations to case-based interventions that target and isolate individual people who are infected, capacity should be sufficient to test:
Hospitalized patients (rapid diagnostics are needed for this population);
Health care workers and workers in essential roles (those in community-facing roles in health and public safety);
Close contacts of confirmed cases; and
Outpatients with symptoms. (This is best accomplished with point-of-care diagnostics in doctors’ offices with guidelines that encourage widespread screening and mandated coverage for testing.)
We estimate that a national capacity of at least 750,000 tests per week would be sufficient to move to case-based interventions when paired with sufficient capacity in supportive public-health infrastructure (e.g., contact tracing).9 In conjunction with more widespread testing, we need to invest in new tools to make it efficient for providers to communicate test results and make data easily accessible to public-health officials working to contain future outbreaks.
Ensure Functioning of the Health Care System. Ensure sufficient critical-care capacity10 in hospitals to be able to immediately expand capacity from 2.8 critical-care beds per 10,000 adults to 5–7 beds per 10,000 adults in the setting of an epidemic or other emergency, allowing for regional variation.11 This target is a minimum, must be adequate for the current and forecasted level of demand, and must be accompanied by adequate staffing. Regional variation in capacity reflecting local needs is acceptable.
Expand access to ventilators in hospitals from 3 per 10,000 adults to a goal of 5–7 ventilators per 10,000 adults.12 This target does not include transport or anesthesia machines. This target is a minimum, must be adequate for the current and forecasted level of demand, and must be accompanied by adequate staffing. Regional variation in capacity reflecting local needs is acceptable.
Maintain access to acute-care hospital beds of at least 30 per 10,000 adults.13 Facilities should have a plan, in the case of a surge in hospital demand, for how the beds would be rapidly flexed from more discretionary uses (e.g., elective procedures) and adequately staffed, with access to adequate supplies of oxygen and other medical supplies.
This health care functioning target would also be met if
critical-care and ventilator capacity does not expand to that level but
COVID-19 incidence is maintained or falls meaningfully below the state’s capacity
to meet critical-care demand. These capacity targets can also be partially met
through the availability of ample mobile health care infrastructures (supported
and perhaps maintained by federal or state governments) that can be distributed
and set up on short notice to hot areas with surge capacity needs.
Increase Supply of Personal Protective Equipment. The Centers for Disease Control and Prevention (CDC) recommends, at a minimum, N95 respirators for hospital staff expected to have direct contact with COVID-19 patients, plus disposable procedural or surgical masks for all other clinical personnel in any health care setting.14 The supply chain should be able to reliably distribute sufficient N95 masks, gloves, and other personal protective equipment to protect health care workers from infection.
Implement Comprehensive COVID-19 Surveillance Systems. The move toward less restrictive physical distancing could precipitate another period of acceleration in case counts. Careful surveillance will be needed to monitor trends in incidence. A high-performing disease surveillance system should be established that leverages:
Widespread and rapid testing at the point of care using cheaper, accessible, and sensitive point-of-care diagnostic tools that are authorized by the Food and Drug Administration (FDA);
Serological testing to gauge background rates of exposure and immunity to inform public-health decision-making about the level of population-based mitigation required to prevent continued spread in the setting of an outbreak; and
A comprehensive national sentinel surveillance system, supported by and coordinated with local public-health systems and health care providers, to track the background rate of infection across states and identify community spread while an outbreak is still small and at a stage in which case-based interventions can prevent a larger outbreak.
ILINet, the surveillance system for influenza-like illness
in the United States, is a potential model for SARS-CoV-2 surveillance. To
enable rapid and more effective detection and case management, SARS-CoV-2
surveillance will also benefit from data sharing and coordination with health care
providers and payers. The CDC should convene an intergovernmental task force,
with outside experts as needed and input from states and the health care
community, to develop and support a new national surveillance system and data
infrastructure for tracking and analyzing COVID-19.
Massively Scale Contact Tracing and Isolation and Quarantine. When a new case of COVID-19 is diagnosed, the patient should be isolated either at home or in a hospital, depending on the level of care he or she requires. Current CDC guidelines recommend seven days of isolation.15 Home isolation can be enforced using technology such as GPS tracking on cell phone apps. Also, the close contacts of confirmed cases (as defined by the CDC16) should be quarantined and monitored daily for 14 days. Monitoring of international travelers is also recommended.17
To scale these interventions to accommodate thousands of
daily cases and tens of thousands of daily contacts, public-health
infrastructure will need to be dramatically scaled up throughout the country,
in coordination with the improving capacity of health care providers to
prevent, diagnose, and treat COVID-19 cases.
The task force should also be charged with developing and
overseeing an initiative to:
Surge the existing public-health workforce to conduct case finding and contact tracing;
Enable rapid reporting to state, local, and federal health authorities, through the public-health workforce and electronic data sharing from health care providers and labs; and
Develop and field a technological approach to enable rapid data entry, reporting, and support for isolation, quarantine, and safe community-based treatment of affected individuals.
Offer Voluntary Local Isolation and Quarantine. Comfortable, free facilities should be provided for cases and their contacts who prefer local isolation, quarantine, and treatment away from home. For example, a member of a large household may wish to recover in a hotel room that has been repurposed rather than risk infecting family members. Isolation and quarantine away from home should not be mandatory or compelled by force.
The Federal Emergency Management Agency is the
lead agency tasked with coordinating with state and local jurisdictions to
stand up appropriate isolation and quarantine facilities. Field hospitals,
dormitories, hotels, and military barracks may be appropriated for this purpose.
Encourage the Public to Wear Masks. There is emerging evidence that asymptomatic and presymptomatic transmission of COVID-19 is possible,18 which complicates efforts to pursue case-based interventions. To reduce this risk during Phase I, everyone, including people without symptoms, should be encouraged to wear nonmedical fabric face masks while in public.19
Face masks will be most effective at slowing the spread of SARS-CoV-2 if they are widely used, because they may help prevent people who are asymptomatically infected from transmitting the disease unknowingly. Face masks are used widely by members of the public in some countries that have successfully managed their outbreaks, including South Korea and Hong Kong.20 The World Health Organization (WHO) recommended members of the public use face masks in the event of a severe influenza pandemic.21
However, personal protective equipment should continue to be reserved for health care workers until supplies are sufficient for them and abundant. For this reason, right now members of the general public should opt to wear nonmedical fabric face masks when going out in public. The CDC should issue guidelines on the proper design of such nonmedical fabric face masks. Consumers may be able to fashion these masks themselves using available washable materials, or they may become available in the consumer marketplace.
Trigger for Moving to Phase II
A state can safely proceed to Phase II when it has achieved
all the following:
A sustained reduction in cases for at least 14 days,
Hospitals in the state are safely able to treat all patients requiring hospitalization without resorting to crisis standards of care,22
The state is able to test all people with COVID-19 symptoms, and
The state is able to conduct active monitoring of confirmed cases and their contacts.23
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.
High-contact settings such as schools should continue to
review and implement physical distancing measures with guidance from the CDC
and input from local officials. Health officials should recommend increased
social hygiene measures and cleaning of shared surfaces.
For older adults (those over 60 years old), those with
underlying health conditions, and other populations at heightened risk from
COVID-19, it should still be recommended that they limit time in the community
during Phase II. This recommendation may change if an effective therapeutic
becomes available.
We need to consider these activities on a coordinated,
regional basis through multistate cooperation. While state and local
governments maintain sovereignty over issues related to their public-health
response, coordination based on regions that cross state boundaries will be crucial.
Large states with multiple urban areas and rural regions may implement
reopening at a regional level. States that share major metropolitan areas (for
example, New York, New Jersey, and Connecticut) should assure that the
conditions for reopening these areas are met across the relevant state
boundaries.
Goals
The goals of Phase II are to:
Lift strict physical distancing measures in a
concerted and careful fashion,
Allow the vast majority of businesses and
schools to open, and
Continue to control SARS-CoV-2 transmission so
we do not revert back to Phase I.
The adoption of these Phase II measures will require a
careful balance. We will need to constantly reevaluate the implementation of
these measures based on available surveillance data, and we will need to be
ready to adjust our approach over time according to the epidemiology of local,
national, and global spread. This is especially true as we transition from one
phase to the next.
Thresholds for Action
Trigger to Lift Physical Distancing Measures. Once
the criteria for the transition from Phase I to Phase II have been met and we
begin to move away from the “slow the spread” period, leaders at the state
level should begin an incremental easing of physical distancing measures. This
should be done gradually and should be paired with increased surveillance for new
cases. State officials should make decisions about the selection and timing of
restrictions to lift based on their local contexts. Restrictions should be
eased gradually, with sufficient time between each adjustment to carefully
monitor for resurgence of transmission.
Trigger for Returning to Phase I, “Slow the Spread.” As
physical distancing is gradually eased, surveillance will be essential for
quickly identifying an increase in cases in the state. A state should
revert to Phase I and continue “slow the spread” if a substantial number of
cases cannot be traced back to known cases, if there is a sustained rise in new
cases for five days, or if hospitals in the state are
no longer able to safely treat all patients requiring hospitalization.
Trigger for Moving to Phase III. Once a vaccine has
been developed, has been tested for safety and efficacy, and receives FDA
emergency use authorization,24 or there are other therapeutic options that can be used for preventive or treatment indications and that have a measurable impact on disease activity and can help rescue very sick patients, states can move to Phase III.
Steps Required in Phase II
Implement Case-Based Interventions. Using the public-health capacities developed in Phase I, every confirmed case should be isolated either at home, in a hospital, or (voluntarily) in a local isolation facility for at least seven days, or according to the latest CDC guidance. People awaiting test results should be advised to quarantine until their results are returned.
The
close contacts of confirmed cases should be traced and placed under home or
central quarantine, with active daily monitoring for at least 14 days, or
according to the latest CDC guidance. Diagnostic tests should be immediately
administered to any close contacts who develop symptoms.
Begin to Relax Physical Distancing Measures. General physical distancing precautions should still be the norm during Phase II, including teleworking (as much as possible), maintaining hand hygiene and respiratory etiquette, wearing a mask in public, regularly disinfecting high-touch surfaces, and initially limiting social gatherings to fewer than 50 people. These recommendations should be augmented through technological solutions to understand physical distancing behaviors and adjust risk messaging as needed. This should be accomplished through partnerships with the private sector, with careful attention paid to preserving privacy and avoiding coercive means to encourage compliance.
As children return to school and daycare (i.e., high-contact
settings) and people return to high-density workplaces, leaders of these
organizations should continue to review and implement physical distancing
measures based on guidance from the CDC for schools and businesses.25
Special Care for Vulnerable Populations. While easing of physical distancing is taking place, highly vulnerable populations,26 such as individuals older than age 60 and those with compromised immune systems or compromised lung and heart function, should continue to engage in physical distancing as much as possible until a vaccine is available, an effective treatment is available, or there is no longer community transmission. Special attention should be paid to long-term-care facilities and nursing homes.27 These facilities will need to maintain high levels of infection prevention and control efforts and limit visitors to prevent outbreaks.
If a treatment or prophylactic, such as a monoclonal antibody,28 becomes available, high-risk and vulnerable populations should be prioritized to receive it, to both protect those individuals and reduce the likelihood of an increase in severe illnesses and additional patient surge in hospital intensive care units (ICUs).
Accelerate the Development of Therapeutics. Therapeutics play an important role in caring for those who are sick. Accelerating the research, development, production, and distribution of safe and effective therapeutics is a top priority. With effective development strategies and early investments in commercial-scale manufacturing, a successful therapeutic could receive emergency use authorization or approval as early as the summer or fall, if trials demonstrate that it meets either standard.
Therapeutics can serve a number of roles. First, they can
serve as a prophylaxis to help prevent infection in those at greatest risk of
infection, such as front-line health care workers, or those at risk of bad
outcomes, such as individuals with preexisting health conditions and those who
are immunocompromised. Such a treatment could include a recombinant antibody
that can target the virus surface antigens. As an example, researchers
successfully developed such a therapeutic against Ebola. These antibody drugs
can also be used to treat early infection or as a postexposure prophylaxis.
Other therapeutics might include antiviral drugs that target features of how the virus replicates. These drugs can be used to treat people who are critically ill or earlier in the course of disease for those at risk of developing a complication. Antiviral drugs can also be used as postexposure prophylaxis, depending on their safety profile. Postexposure prophylaxis and products that shorten the duration and intensity of viral shedding may affect the effective reproduction number only modestly. In addition, immune-modulating treatments may prove to be helpful in mitigating severe lung complications in some patients. A number of promising drugs are in early and mid-stage development.
At a minimum, the optimal profile for a therapeutic that
will affect the risk from future spread is one that meaningfully reduces the
risk of death or severe disease and perhaps prevents the onset of symptoms or
progression to severe disease in those exposed. Oral administration at the
outpatient level would be ideal, but alternative administration requirements
(e.g., infusion and jet injections) could also be scaled, with sufficient
planning.
While private industry has
already organized a large task force to share information and capabilities to
rapidly advance promising therapies, we need a commensurate focus by federal
agencies to make sure the best possible resources are brought to this mission.
Federal agencies should join organized efforts already underway in the private
sector.
Identify Those Who Are Immune. Serology is a method used to identify evidence of immunity in someone who has recovered from infection. With accurate and widely available serological testing, we can identify people who are immune and therefore no longer vulnerable to infection. While we need to better understand the strength of the immune response in mild cases and how long people remain immune from reinfection, we know there is a period where most people will have sufficient antibodies to offer protection. People who are immune could:
Return to work,
Serve in high-risk roles such as those at the front lines of the health care system, and
Serve in roles that support community functioning for people who are still physically distancing (e.g., the elderly who continue to quarantine at home).
To use serology in this way, serological
assays are needed and should be widely available, accurate, rapid, and low cost.
Such assays have already been developed by researchers, but they have not yet
been fully validated and are not available at scale.
A task force comprised of senior leaders from the CDC, the Biomedical Advanced Research and Development Authority, the National Institute of Allergy and Infectious Diseases, the Department of Defense (DOD), the FDA, academia, and key private-sector groups (e.g., serological manufacturing companies) should be tasked to oversee the development, production, distribution, data collection, serological survey designs, and analytics for use of serology at scale.29
Trigger for Moving to Phase III
Once a vaccine has been developed, has been tested for safety and efficacy, and receives FDA emergency use authorization,30 states can move to Phase III.
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.
Goals
The goals of safe and effective technologies for controlling
transmission are to:
Prevent infection;
Treat those with early disease to prevent bad
outcomes;
Provide a prophylaxis for those exposed to
infection to prevent them from developing disease or reduce its severity;
In the case of a vaccine, build population-level
immunity to the virus in order to reduce illness and death and stop or greatly
slow spread; and
Enable the lifting of all physical distancing
measures.
Thresholds for Action
Trigger to Begin Manufacturing Scale-Up and Vaccine or Therapeutic Prioritization Planning. As soon as a vaccine or therapeutic looks promising in pivotal clinical trials (i.e., it has been shown to be safe and looks like it will also be effective),31 the US government should work with industry to begin planning for mass manufacturing, distribution, and administration. New provisions enacted under the recently passed the Coronavirus Aid, Relief, and Economic Security Act allow for large-scale manufacturing of promising therapies, in advance of approval, to help make sure there will be adequate supply available for mass distribution, should a product demonstrate that it is safe and effective and win regulatory approval.
Trigger for Switch Toward Mass Vaccination. Once availability of a vaccine or therapeutic is able to meet demand, vaccination can expand beyond priority groups. The CDC, state public-health agencies, and vaccine developers should work together to plan for and execute mass vaccination of large populations in the US. This planning can begin before Phase III because preparation can be made regardless of vaccine availability.
Steps to Take in Phase III
Vaccine or Therapeutic Production. Once a safe and effective vaccine or therapeutic has been licensed, it will need to be quickly manufactured at scale. The Public Health Emergency Medical Countermeasures enterprise,32 in coordination with pharmaceutical companies and other private-sector stakeholders, should continue to plan for and implement mass production capable of quickly meeting US demand.
Vaccine or Therapeutic Prioritization—When Supply Is Still Limited. The CDC, the National Institutes of Health, the Office of the Assistant Secretary for Preparedness and Response, the DOD, and other stakeholders should revise prior influenza vaccine prioritization guidance to apply specifically to COVID-19.33 The new prioritization guidance for the COVID-19 vaccine should identify priority groups for targeted distribution when a safe and effective vaccine starts to become available. The guidance should be transparent and explain the reasoning for priorities, including the populations in which the vaccine was studied, and should be a phased approach that expands to additional priority groups as vaccine availability expands. The guidance should be reflected in COVID-19 payment policies implemented by the Centers for Medicare & Medicaid Services (CMS) and private insurers, with treatment available at no cost to individuals who meet the priority guidance and a mechanism for reimbursement for individuals who are uninsured.
Mass Vaccination or Therapeutic Distribution—When Supply Is Abundant. The CDC should work with state and local health officials, health care providers, CMS and health insurers, and other public-health stakeholders to create a national plan for how mass vaccination will be carried out across the country. This plan should identify who will administer vaccinations, where vaccines will be offered, and how data will be collected on vaccination rates, as well as possible adverse events from the vaccine. Indemnification of vaccine developers and manufacturers should also be considered. Congress could enact legislation to support a process for compensation of any individual who has an adverse event from the vaccine, which requires medical care.
Global Vaccine Scale-Up and Vaccination. The CDC, the US Agency for International Development, the State Department, and other US stakeholders should continue to work with WHO and other international organizations and national leaders to plan for how the US will assist other countries (particularly low- and middle-income countries) with obtaining vaccine and implementing mass vaccination. Support from the United States and higher-income nations will be critical for controlling the virus globally and saving lives around the world, as well as reducing the impact that future waves of the pandemic may have on the US population.
Serological Surveys to Determine Population Immunity. One key input for understanding the population at risk is the fraction of the population who have recovered and are protected against reinfection. If a sufficiently high fraction of the population has become immune either through natural recovery or vaccination, remaining restrictions can be lifted. The CDC should be the lead agency for coordinating ongoing serological surveys.
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.
Develop Vaccines for Novel Viruses in Months, Not Years. In response to COVID-19 and in preparation for the next previously unidentified health threat (“Disease X”34), the United States should lead the way by setting an ambitious goal of rapidly developing medical countermeasures for novel or unknown threats in months, not years. A dedicated strategy, program, and funding will be needed to create the ability at existing agencies within the US Department of Health and Human Services and DOD to quickly develop flexible platforms and countermeasures for any type of novel pathogen.35 This strategy should include supporting flexible manufacturing capacity to scale up production to a global level in an emergency.
Modernize and Fortify the Health Care System. We must improve our hospital-bed and ICU capacity to accommodate large surges of patients through public-private partnerships, for example, by enhancing the Hospital Preparedness Program36 and the Public Health Emergency Preparedness Cooperative Agreement37 and emphasizing preparedness in federal health care programs (e.g., the CMS38 and the Department of Veterans Affairs39). We must also expand the supply chain of personal protective equipment and further the development of crisis standards of care. To reduce future burdens on our critical-care systems, we must also support our primary and community care capabilities to identify populations at elevated risk, detect cases early, and manage them at home or in the community more effectively. Health care payers have been implementing payment reforms to support better screening and population health management. Emergency supplemental payments to health care providers in the current pandemic and future health care payments should be linked to establishing better surge capacity for severe cases and stronger capabilities to partner with public-health authorities to contain outbreaks and reduce the burden on hospitals.
Establish a National Infectious Disease Forecasting Center. Given the important role of infectious disease modeling in supporting public-health decision-making, we should increase our nation’s capacity to use infectious disease modeling40 to support public-health decision-making by establishing a national infectious disease forecasting center. This permanent federal institution would function similarly to the National Weather Service, providing a centralized capability for both producing models and undertaking investigations to improve methods used to advance basic science, data science, and visualization capabilities. It would also provide decision support to public-health agencies based on modeling and analytic results.
Governance. We need to move away from a decentralized system that promotes unequal implementation of preparedness measures across the nation and toward a more coordinated execution of response. We should develop clear and effective plans for the implementation of public-health measures such as quarantine and the unification of actions made by state and local health departments. Outbreaks are matters of regional—and more typically national—concern. Preparedness for public-health emergencies should be elevated as a function in the White House, with a coordinating function analogous to the director of national intelligence.
Acknowledgments
The authors are grateful for policy input and review of the document by Anita Cicero, JD; Thomas Inglesby, MD; Eric Toner, MD; Elena Martin, MPH; Dylan George, PhD; Jason Asher, PhD; and Trevor Bedford, PhD.
About the Authors
Scott Gottlieb is
a resident fellow at the American Enterprise Institute and was the Food and
Drug Administration commissioner from 2017 to 2019. He serves on the boards of Pfizer
Inc. and Illumina.
Mark McClellan,
who directs the Duke-Margolis Center for Health Policy, was commissioner of the
Food and Drug Administration from 2002 to 2004. He is an independent board
member at Alignment Health Care, Cigna, Johnson & Johnson, and Seer. He is
a co-chair of the Health Care Payment Learning and Action Network and receives
advisory fees from Arsenal Capital, CRG, and Mitre.
Lauren Silvis is
a senior vice president at Tempus Inc. and was previously the deputy director
of the Food and Drug Administration’s medical device center and the agency’s
chief of staff from 2017 to 2019.
Caitlin Rivers is
an epidemiologist and assistant professor at the Johns Hopkins Center for
Health Security.
Crystal Watson is a health security expert and assistant professor at the Johns Hopkins Center for Health Security.
4. Institute of Medicine, Crisis Standards of Care: Summary of a Workshop Series (Washington, DC: National Academies Press, 2010), https://www.ncbi.nlm.nih.gov/books/NBK32749/.
5. Centers for Disease Control and Prevention, “Interim US Guidance for Risk Assessment and Public Health Management of Persons with Potential Coronavirus Disease 2019 (COVID-19) Exposures: Geographic Risk and Contacts of Laboratory-Confirmed Cases,” March 22, 2020, https://www.cdc.gov/coronavirus/2019-ncov/php/risk-assessment.html.
7. Qun Li et al., “Early Transmission Dynamics in Wuhan, China, of Novel Coronavirus–Infected Pneumonia,” New England Journal of Medicine 382 (March 2020): 1199–207, https://www.nejm.org/doi/full/10.1056/NEJMoa2001316.
8. Centers for Disease Control and Prevention, “Interim
US Guidance for Risk Assessment and Public Health Management of Persons with
Potential Coronavirus Disease 2019 (COVID-19) Exposures.”
9. During the 2017–18
flu season (which was particularly severe), there were 18,000,000–27,000,000 medical visits for
influenza-like illness spread out over approximately 32 weeks, averaging
562,000–844,000 visits per
week. However, those visits were not evenly distributed throughout the season,
and peak demand was higher, so we estimate a national capacity of approximately
750,000 would meet demand. South Korea has tested 1 in 170 people,
cumulatively. To do the same, we would need to test 1.9 million people, which
we could achieve in around 2.5 weeks with a capacity of 750,000/week.
11. Preliminary research suggests that a Wuhan-like outbreak in the United States would require 2.1 to 4.9 critical care beds per 10,000 adults. However, a majority of those beds are in use for non-COVID-19 patients requiring critical care for other conditions. We estimate that approximately 5–7 beds per 10,000 adults would accommodate both patient groups. Ruoran Li et al., “The Demand for Inpatient and ICU Beds for COVID-19 in the US: Lessons from Chinese Cities” (working paper, March 16, 2020), https://www.medrxiv.org/content/10.1101/2020.03.09.20033241v2.full.pdf.
12. Halpern and See Tan, “U.S. ICU Resource
Availability for COVID-19.”
13. Halpern and See Tan, “U.S. ICU Resource
Availability for COVID-19.”
16. Centers for Disease Control and Prevention, “Interim
US Guidance for Risk Assessment and Public Health Management of Persons with
Potential Coronavirus Disease 2019 (COVID-19) Exposures.”
22. Institute of Medicine, Crisis Standards of Care.
23. Centers for Disease Control and Prevention, “Interim
US Guidance for Risk Assessment and Public Health Management of Persons with
Potential Coronavirus Disease 2019 (COVID-19) Exposures.”
24. Feng et al., “Rational Use of Face Masks in the
COVID-19 Pandemic.”
37. Centers for Disease Control and Prevention, “Public Health Emergency Preparedness (PHEP) Cooperative Agreement,” March 27, 2020, https://www.cdc.gov/cpr/readiness/phep.htm.
How Will We Know When It’s Time to Reopen the Nation?: Experts offer four benchmarks that can serve as a guide for cities and states, eliminating some of the guesswork. By Aaron E. Carroll
Times Square on Friday. Angela Weiss/Agence France-Presse — Getty Images
Everyone wants to know when we are going to be able to leave our homes and reopen the United States. That’s the wrong way to frame it.
The better question is: “How will we know when to reopen the country?”
Any date that is currently being thrown around is just a guess. It’s pulled out of the air.
To this point, Americans have been reacting, often too late, and rarely with data. Most of us are engaging in social distancing because leaders have seen what’s happening in Europe or in New York; they want to avoid getting there; and we don’t have the testing available to know where coronavirus hot spots really are.
Since the virus appears to be everywhere, we have to shut everything down. That’s unlikely to be the way we’ll exit, though.
Some cities or states will recover sooner than others. It’s helpful to have criteria by which cities or states could determine they’re ready. A recent American Enterprise Institute report by Scott Gottlieb, Caitlin Rivers, Mark B. McClellan, Lauren Silvis and Crystal Watson staked out some goal posts.
Hospitals in the state must be able to safely treat all patients requiring hospitalization, without resorting to crisis standards of care.
Other cities and states fear that they will approach New York City’s state of crisis. They’re trying to increase the number of available beds and ventilators — as well as doctors, nurses and other health care providers — to make sure they aren’t overwhelmed in their capacity to provide care to all those who need it.
This is the most immediate bar, and the focus of most public health officials’ attention. At the moment, there’s no reason to believe any area is over a surge of cases, and analysts’ models predict many places won’t peak for weeks to come.
A state needs to be able to at least test everyone who has symptoms.
Dr. Gottlieb and colleagues estimate that the nation would need to have the capacity to run 750,000 tests a week — this is after things have calmed down greatly. There are times we might need even more.
“The 750,000 number should be viewed as a reasonable expectation for when we haven’t been having any major pockets or regional outbreaks to manage,” said Mark McClellan, an author of the report and a professor of business, medicine and policy at Duke. “If more testing to help contain outbreaks and potential outbreaks is needed, which seems very plausible, especially early on, the number would need to be significantly larger. We’ll also have to do some surveillance of people without symptoms, especially in higher-risk settings.”
A national estimate means less in deciding whether a state can reopen than its local capabilities. A state would need to be sure it could test every single person who might be infected, and have the results in a timely manner. That would be the only way to achieve the next requirement.
The state is able to conduct monitoring of confirmed cases and contacts.
A robust system of contact tracing and isolation is the only thing that can prevent an outbreak and a resulting lockdown from recurring. Every time an individual tests positive, the public health infrastructure needs to be able to determine whom that person has been in close contact with, find those people, and have them go into isolation or quarantine until it’s established they aren’t infected, too.
This will be a big challenge for most areas. Other countries have relied on cellphone tracking technology to determine whom people have been near. We don’t have anything like that ready, nor is it even clear we’d allow it. The United States also doesn’t have enough people working in public health in many areas to carry out this task.
Building that capacity will take significant time and money, and the country hasn’t even started.
There must be a sustained reduction in cases for at least 14 days.
Because it can take up to two weeks for symptoms to emerge, any infections that have already happened can take that long to appear. If the number of cases in an area is dropping steadily for that much time, however, public health officials can be reasonably comfortable that suppression has been achieved, defined by every infected person infecting fewer than one other.
In suppression, cases will dwindle at an exponential fashion, just as they rose. It’s not possible to set a benchmark number for every state because the number of infections that will be manageable in any area depends on the local population and the public health system’s ability to handle sporadic cases.
“We wanted to suggest criteria that would allow locations to safely and thoughtfully begin to reopen, but what that looks like exactly will vary from state to state,” said Caitlin Rivers, another author of the report and an epidemiologist at the Johns Hopkins Center for Health Security. “We therefore included some flexibility for jurisdictions to tailor these criteria to their local context.”
These four criteria are a baseline. Other experts think we will need to add serological testing, which is different from the viral detection going on now. This type of testing looks for antibodies in the blood that our bodies created to fight the infection, not the infection itself. These tests can be much cheaper and faster than the ones we’re currently using to detect the virus in sick people.
Testing for antibodies will tell us how many people in a community have already been infected, as opposed to currently infected, and may also provide information about future immunity.
Gregg Gonsalves, a professor of epidemiology and law at Yale, said: “I’d feel better if we had serological testing, and could preferentially allow those who are antibody positive and no longer infectious to return to work first. The point is, though, that we are nowhere even near accomplishing any of these criteria. Opening up before then will be met with a resurgence of the virus.”
He added, “That’s the thing that keeps me up every night.”
Until we get a vaccine or effective drug treatments, focusing on these major criteria, and directing efforts toward them, should help us determine how we are progressing locally, and how we might achieve each goal.
It would also prevent us from offering false hope about when America can start reopening. Instead of guesses, people could have clear answers about when they might be able to go back to a closer-to-normal way of life.
Times Square on New Year’s 2020. Angel Colmenares/EPA, via Shutterstock
The coronavirus has left death and devastation in its wake. But as we've said since the beginning, this shutdown costs lives, too, and here's the toll.
More than 1 in 10 Americans thrown out of work, higher taxes to come, businesses collapsing, mental health declining, poverty rising and with it, life expectancy falling. We're hearing that there was pushback against the shutdown in early February.
Of course, there was and quite right, too. President Trump's instincts on this have been right all along. He's the one that has to consider all the implications of any decision, including the social, economic, and yes, public health devastation of a shutdown.
As the shutdown toll grows, so has the demand for a better, more sustainable antivirus plan. We've said it different ways, but it's all the same thing: Reopen America safely, but soon.
I've read the ideas that are out there for how we move out of shutdown. Frankly, none of them makes sense, except the one put together by a world-renowned team of scientists and entrepreneurs that we will present to you.
First, let's get the bad ideas out of the way. The central truth of our current situation is that it's not just as I said a few weeks ago, that the cure is worse than the disease. This cure is not even a cure.
The minute you lift the lockdowns, the virus starts spreading again, whether that's May, June, July, August or Christmas. That's the central floor in the first bad idea for reopening. Lift the lockdown now but reapply it until we get a vaccine.
MSNBC's Zeke Emanuel talks about shutdown 2.0, 3.0, 4.0. How about, just "no." Anyone pushing the recurring shutdown idea has no clue about how the economy actually works. Uncertainty is a killer for business, for consumers and for workers. We need to reopen and stay open.
Another terrible idea is the one we told you about last week. Governments in Europe are looking at immunity passports or certificates for those who've had coronavirus. Our own Dr. Fauci said on Friday that immunity certificates, "might actually have some merit under certain circumstances."
Again, no. This has no merit under any circumstances. Of course, we respect Dr. Fauci's medical expertise, but this is a policy idea that would be an Orwellian nightmare, like the past laws they had in South Africa at the height of apartheid.
To be effective, to bring certainty to business, to maximize our chances of getting that big bounce-back recovery working Americans so desperately need, the right plan to reopen America has to be safe, of course, based on science, but also simple.
Government antibody surveillance, leading to antibody passes would create a class of zero positive elites, and an incentive for people desperate for work to get infected. I hope no one in the White House is wasting one second on such a monstrous inhuman scheme. It would be totally unacceptable to the American people, let alone Trump supporters.
Another example of technocratic hubris is the plan being pushed by former FDA head Scott Gottlieb. This is the one the establishment group seems to be coalescing around. So that alone should make you suspicious of it.
As part of a comically complicated scheme with different phases and benchmarks for different parts of the country, this plan would use mass virus testing, not antibody testing -- as Dr. Fauci puts it, to identify, isolate, contact, trace everyone who gets the virus.
But the latest data tells us that many millions of Americans have or will get the virus. The idea that the government can identify each of them, isolate them somewhere for weeks, trace all their contacts -- it's insane.
And now we know that Apple and Google are right behind it, ready to build their surveillance empires on the back of this crisis. Let's call it the Gottlieb-Apple-Google plan or "GAG" for short. It's a technocrat's dream and America's nightmare. No.
To be effective, to bring certainty to business, to maximize our chances of getting that big bounce-back recovery working Americans so desperately need, the right plan to reopen America has to be safe, of course, based on science, but also simple. That's the plan we'll present to you.
And here are the people who put it together. Stanford University Professor of Epidemiology, Dr. John Ioannidis; Stanford Associate Professor of Population Health, Eran Bendavid, and joining us live, Stanford University Professor of Medicine, Dr. Jay Bhattacharya; biophysicist and medical investor, Dr. Andrew Bogan, and entrepreneur and the founder of JetBlue, David Neeleman.
Uncertainty is a killer for business, for consumers and for workers. We need to reopen and stay open.
Here are the key elements of their plan, and we should be clear that it is intended to go into full effect, May 1st, after the current White House guidelines expire.
Step one: Get accurate data about how widespread and how deadly coronavirus really is. The statistics we're seeing right now are totally wrong. They reflect the number of tests, not the real number of infections.
To get the real number, the Stanford team has just carried out the world's first large scale community antibody sample survey right here in the Bay Area where I'm speaking to you from, Santa Clara County. It was the first in the nation to identify community transmission of coronavirus. The official statistics claim there are about 1,600 cases of coronavirus here.
Based on early indications and similar testing elsewhere, the actual number could be much, much higher. That means coronavirus is much more contagious but much less deadly than we've been told.
So, here's recommendation one: Instead of pursuing government antibody surveillance for every American, the White House should immediately commission continuous community antibody sampling nationwide, so we get a true picture of the spread of this virus.
Second step: Get accurate data about who is most vulnerable. Just saying the elderly and those with underlying health conditions is too vague. How old? Which health conditions? How severe? How much virus were they exposed to? That is a huge part of this story. That is why young people like some of our health care heroes are dying, despite being in good health.
Don't waste time identifying, isolating and contact tracing everyone who has got the virus. The latest data shows there are multiple millions of them, and the vast majority will be fine. Instead, put the effort into tracing the medical histories of the people who so tragically died.
Unbelievably, our hospitals are not collecting that data. So, there's the second recommendation: The White House should mandate the collection and publication of what's known as, "morbidity data" -- detailed information about the health conditions of coronavirus fatalities. This is especially important.
Now, we know more about how this virus is transmitted. Early guidance was wrong and dangerous, focusing on surface transmission, hand washing, face touching and so on. We now know the virus can be passed on through airborne droplets that can be breathed in.
So it's likely that the shutdowns actually hurt the most vulnerable, infected, but asymptomatic people were sent back to multigenerational homes into close quarters with their elderly family members. We need better data on infection rates, better data on risk factors. That's what the next few weeks should be about.
Then we go to step three in this science-based plan: Reopen America all at once, not bit by bit. Quarantine and protect the truly vulnerable. If we know that millions more Americans than we thought have already had coronavirus, we don't need to shut down the economy just for a lack of ventilators to take care of the truly vulnerable.
With the information gathered in steps one and two of this plan, we can do a much better job of protecting them. Quarantine the most vulnerable -- not everyone, not even everyone over 65, just those with the specific health risks that have tragically killed thousands already. Keep them inside, give them N-95 masks and make sure no one comes within six feet of them.
Make sure local health services contact and support them, mobilize food banks to help them. Impose much tighter controls in nursing homes and continue to build our reserves of ventilators and PPE to make sure we can cope with anything that comes down the line.
Look, it might be a while before we can fill up a football stadium, but the science-based plan we've outlined for you is simple, it is practical and it is the best way to reopen America safely, but soon.
Adapted from Steve Hilton's monologue from "The Next Revolution" on April 12, 2020.
