How to Partially Reopen Safely During COVID 19

At this point in time, we are starting to see populations reopen, or enter different phases of social distancing.  Some places, like Taiwan, have been able to lift some measures of social distancing with great success.  To a certain degree and with many modifications, schools and some business have opened there with no recurrence of disease at this time.  Denmark has also partially opened and at this time, has a continually decreasing Ro (i.e. how many people an individual with the disease will go on to infect.)  These regions and others, such as New Zealand, and Hong Kong, had lower incidence of disease and subsequently lower death rates due to early lockdown, widespread testing and rapid isolation and quarantine of infected individuals. 

Other regions have had less success.  Germany has had good social distancing measures to date but now may have to lockdown again as their Ro is increasing.   When they partially lifted some social distancing measures their R0 was 0.72.  Now they have an Ro of 0.96 (an Ro greater than 1 means the disease will spread – an Ro of less than one means that the disease will lessen in the population and an Ro of one means that the disease will stay even in the population.)  As their Ro may go above 1, the disease may spread again through the population.  It remains to be seen as to whether Germany will have to reinstate stricter social distancing laws in the future.

 The UK and USA have had massive spread of disease and soaring death rates partly attributed to poor policy, with the UK now having the highest death rates in Europe and the US projected to have 200,000 deaths by the end of this summer.  Other countries relied on theoretical herd immunity and failed.  An epidemiologist in Sweden named Angers Tarnell developed a plan to rely on individual responsibility for social distancing measures, as current laws in Sweden make it difficult to lock down the entire country. These guidelines were made with the hope that personal responsibility would prevent infected individuals from spreading disease through the population. 

Also, guidelines were so concerning that 22 scientists wrote an article in a Swedish newspaper denouncing these policies.  This plea was largely ignored, and the result was a soaring of incidence and death through the population.  Sweden’s failed policies resulted in a high death rate comparable to the US, although the US has a higher number of absolute deaths due to its higher population.

Shutdowns were instigated in many countries in the world with the intent to complete the following: 1. Stop spread of disease and subsequently, death and not overwhelm the health care system 2. Allow health care facilities to accommodate for possible outbreaks/surges of disease, including ramping up production of PPE and manufacturing enough medical supplies to accommodate a surge of sick patients in the event of an outbreak 3. Allow for testing to be ramped up to not only readily test symptomatic but also asymptomatic individuals and 4. Ultimately find a permanent cure, a vaccine.  Partially lifting social distancing measures will have to be completed in phases with certain criteria in place before we reopen. 

There is certainly an economic push to reopen, and quickly.  However, new models suggest that the economic damage is similar with premature opening as with constant, consistent stay at home laws.  To partially reopen successfully, a few things need to be in place.

Firstly, A sustained reduction in the number of cases for a minimum of 14 days which represents one incubation period for the virus.  It is not enough that the cases are low one day, or that we are on “the downside of the curve” because we don’t know what the second half of the curve actually looks like.  If we lift social distancing measures prematurely, we can see a surge of disease through the population which will result in unnecessary hospitalizations and deaths.  This is why we need to see that cases that are continuously suppressed for a long period of time.

Secondly, we need universal testing, especially because so many people with COVID 19 are asymptomatic.  We have to be careful about the test we use.  A test is available that can rapidly detect components of the virus and can therefore immediately detect infected people, but it does not have a very good sensitivity (i.e it misses a lot of positive COVID 19 cases). This means that an infected person who falsely tested negative may go on to spread disease, especially if they don’t know that they are infected. 

Improving sensitivity of rapid testing is also important because many people with COVID 19 spread the disease before they actually develop symptoms or don’t even develop any symptoms at all (we call these asymptomatic spreaders.) Another test is available that test antibodies in your blood.

The problem with this test is that it takes time for your system to develop antibodies, and in that time, you can spread the disease, as you may not know that you even have it.   Antibody testing can help tell us how much the disease has spread through the population but does not tell us if you are immune to it.  This is because unfortunately, having antibodies does not automatically mean you have immunity to the disease and more studies are needed to validate this.

The state needs to test all people who have symptoms and also screen for asymptomatic carriers.  Because of the high incidence of asymptomatic spreaders, it becomes very difficult to stop the spread of disease without locating and identifying these cases.  This means that the number of tests needed to be completed daily is extremely high.  In the US, one study shows that they would need 750,000 tests per day minimum, including routine testing of hospitalized patients, healthcare workers and contacts of infectious patients.  Other studies say that the US would need even more than that; 5 million tests per day at least and should ramp up to 20 million tests per day by mid-June to quickly identify infected individuals and prevent spread through the population.  Another Harvard paper states that we need 10’s of millions of tests per day in the US to ramp up testing.  In Canada, numbers may be different depending on the number of people infected and number of outbreaks. 

However, in all cases, without systematic and widespread testing, an outbreak can occur and spread very quickly through any population.  In addition to testing, you would also need to trace and immediately contact infected people to sequester them from the rest of the population, as they do in South Korea.  Some countries have a mandatory app or GPS system that allows people who have been in contact with infected individuals to be immediately identified, contacted and sequestered to help prevent spread of disease. A coordinated, national response plan is also needed to identify when we reinstate lockdown if an outbreak occurs and a part of that requires hiring more healthcare workers to help implement that process.

Hospitals and health care systems must also be able to accommodate a surge of patients if an outbreak occurs. You also need to make sure your health care system can handle an outbreak if it happens (this is called surge planning).  One US set of guidelines recommends that local intensive care units should have at least 5-7 beds per 10,000 people in the population, minimum, but the total number of ICU beds will likely vary from region to region. These facilities would also need 5-7 ventilators and 30 acute care hospital beds per 10,000 people.  We cannot guarantee that we can help every person sick from COVID 19 without accommodating for outbreaks. 

Other medical supplies must also be accommodated for in the event of a surge, such as medications and oximeters.  This includes an increased supply of PPE such as N95 masks for all health care workers but also gowns, gloves etc. 

There should also be a steady supply of PPE, preferably with manufacturing available for people in that region to ensure that the supply chain is not disrupted.  Interestingly, universal face masks are now thought to help slow spread of disease by asymptomatic individuals, as are worn in South Korea and Hong Kong.

Clearly, partial reopening must be a methodical, planned out process with all of these factors in place.   Long term proper planning will minimize economic damage and loss of life.

About the author

Asia Metro Editor

Surjit Singh Flora
editor@asiametro.ca

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