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How can the United States transition from the broadscale strategy of mitigating the spread of COVID-19 through shutdowns and physical distancing to a more focused strategy of containment, where infected individuals are quickly identified and isolated to prevent larger outbreaks?
In a viewpoint published in JAMA on April 17, Rochelle Walensky, MD, MPH, chief of Infectious Diseases at Massachusetts General Hospital, and Carlos del Rio, MD, from the Emory University School of Medicine, identify several key components of a successful reopening plan:
- Decreasing the population density of daily activities such as work, school and social gatherings
- Large scale serological (antibody) testing to better understand how much of the population has been exposed to the disease and identify those who are potentially immune
- Rapid, easily accessible viral testing of individuals with COVID-19 symptoms for quick identification and isolation, as well as intermittent testing for individuals in roles with exposure to others
- Additional resources for those in vulnerable populations who have been significantly impacted by the pandemic
- At least a $5 billion investment in public health to provide the infrastructure needed to support testing and containment strategies
Dr. Walensky, who is also a Steve and Deborah Gorlin MGH Research Scholar, and Dr. del Rio, believe that as infection rates start to decrease in mid- to late-May, there will be a staccato progression toward the restoration of a normal life. In the absence of a game-changing treatment or vaccine for COVID-19, however, the road to reopening will likely have many stops and starts.
“Despite how challenging it is to answer the ‘when’ question, addressing the ‘how’ is no less daunting,” Walensky and del Rio write. Both of those questions will hinge on significantly scaling up testing.
Why Testing Is Key
Serologic testing is needed to identify immunoglobulins (antibodies in the blood) specific for SARS-COV-2 in individuals who have been exposed to the virus. Since testing thus far has been limited to those with more severe symptoms, health officials still don’t know how many individuals in the population have had the disease and shown mild to no symptoms.
With an estimated reproduction number of two to three (one person with the virus infects an average of two to three others in a completely susceptible population), the benefits of herd immunity will only start to occur when 50%-66% of the population has been infected with the virus.
The hope is that those who have been exposed to SARS-COV-2, recovered from it, and have developed antibodies against it, will be adequately protected from reinfection until a vaccine is clinically available. However, it is still not clear if this is the case.
The second crucial need is to rapidly scale up virologic testing to quickly identify individuals infected with the virus so they can be isolated and their recent contacts quarantined to prevent large scale breakouts. These tests must be easy to perform, inexpensive and accessible outside of the health care system for anyone with symptoms of COVID-19, the authors write.
Because asymptomatic and presymptomatic transmission is possible, additional wide scale intermittent testing may be required, particularly for those who work in settings with extensive exposure to others—health care, schools, retail, etc.
This testing will only work if it is followed up with effective containment and isolation strategies—not only for the infected person but for their recent contacts as well, the authors caution. Smartphone or web-based contact-tracing tools will likely be necessary to identify and isolate contacts in enough time to mitigate the spread of the disease.
Extra care will have to be taken in devising strategies to care for those in vulnerable populations, such as those living in close quarters who are unable to self-isolate, individuals experiencing homelessness and primary wage earners who may avoid testing if a positive result will compromise their ability to work.
Investing in the Future
Given the extraordinary opportunity cost of remaining closed, the federal government must make at least an estimated $5 B investment to implement the infrastructure needed to support ongoing testing and containment efforts, the authors write. This will include:
- $2.5 billion funding for serologic testing – $10 per test for half the population
- $1 billion funding for rapidly available viral testing for symptomatic individuals (more for spot-checking individuals in high risk roles)
- $1-2 billion to implement web- and phone-based contact-tracing
This estimate does not include the additional costs of protecting the most vulnerable communities and investing in research and development to deliver life-saving therapeutics, diagnostics and vaccines.
The authors note that this investment is small, compared to the over $2 trillion already lost during the two months of shut down.
While the rate of COVID-19 infections is expected to dip over the summer, it is unlikely to disappear completely. Intermittent returns to physical distancing in certain states or regions may be needed as new outbreaks occur.
“I think the first thing we have to recognize is that big crowds—in terms of baseball games, Mardi Gras, festivals—those things are probably not a good idea,” Walensky said in a JAMA webinar discussing the article. “At least until we recognize that we have this under control and there is widespread testing.”
Businesses should consider work schedules that limit office crowding such as having employees work remotely every other day or every other week. Health care providers should look for ways to reduce patient density in waiting rooms by spacing out appointments and expanding to evenings and weekends.
Restaurants and consumer-facing businesses such as retail stores should also take steps to limit their capacity at any given time.
“I am very much interested in having the economy get back on its feet again, but not at the risk of public health,” Walensky says. “I think if we look at the 1918 flu and what happened there, areas that did public health well fared much better than those that didn’t.”
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In this video, Paul Biddinger, MD, director of the Center for Disaster Medicine, and Rochelle Walensky, MD, MPH, chief of Infectious Diseases, answer questions about COVID-19.