An Approach to Reopening the Economy without Pandemic Resurgence
Introduction
Since social and physical distancing, self-quarantine and isolation have been put in practice, the coronavirus pandemic curves have started to flatten according to how stringently they are implemented in the states around the country. As the situation improves the debate about lifting restrictions will certainly heat up again: should we allow the economy and industries to continue their free falls until vaccines become widely available, or reopen the country and risk resurgence of the pandemic? Tough problems are usually not solved by direct assaults; they dissolve if you put the proper conditions in place. The basic strategy we need is the same as that used for fighting wildfires. After the flames have passed, firefighters conduct mop-up operations, checking all the hot spots and knocking each and every of them down, in order to prevent fire resurgence. We would like to propose a similarly proactive pandemic management approach to ensure that we can keep the epidemic under control as we resume normality without having to wait for “herd immunity” and further lower the number of cases of infection as we progress forward (see figure 1).
In this proposal we present the preconditions required for reopening the country, the critical measures that must be taken in order to keep the pandemic under control and the key pillars necessitated to ensure the success of these measures.
Two Preconditions for Returning to Normality
In order to keep coronavirus spread under control while reopening the economy, we need to have two necessary preconditions in place:
1. Limited number of new cases
To reopen the economy without a resurgence of cases of infection, we need to maintain current social distancing, self-quarantine and isolation until daily new cases drop to a manageable level. Since current testing is limited in capacity and biased toward those who are symptomatic, regular random sample testing must be conducted for monitoring purpose. Given the fact that the severity of the pandemic varies greatly between regions, it is very likely that each region will achieve the manageable level at different times, requiring enforced travel restrictions between the regions.
2. Adequate testing, contact tracing and treatment capacity
A region’s manageable level of daily new cases for returning to normality should be determined by its capacity for coronavirus and antibody testing and contact tracing. This means that each and every suspected case is tested without delay, contact tracing is accomplished effectively and timely, and all infected are placed in quarantine or hospitalized.
Four Critical Measures
Keeping the epidemic at bay requires a comprehensive set of strategies.
1. Social Distancing and Hygiene
Social distancing has been effective in containing coronavirus spread. In addition to requiring citizens to keep a 6 feet distance wherever possible, sanitizers should be available in all the public places. Face masks should be used when working in closed spaces for long period of time, UV lights and disinfectant sprays, which are less labor- and time-intensive, should be used regularly to eliminate the virus in wide spaces.
2. Coronavirus RNA and Antibody Testing
Each and every suspected case must be tested!
Coronavirus RNA and antibody (Ab) testing should be conducted together as we work toward returning to normality. While RNA testing offers the benefit of detecting virus in a person, it could produce a false negative because viruses are mostly present deep in the lungs and swab sampling often fails to pick them up. RNA testing will also be negative once the virus has been cleared from the body. Ab testing, though has a few days delay, serves as an indicator for infection (IgM) and post-infection immunity (IgG). Additionally, Ab testing is fast, low-cost, as easy to use as a pregnancy test at home, and, therefore, more suitable for regular testing in broad scales.
All testing data should be gathered and analyzed by centralized data systems and can be used for policy and guideline adjustments. The outcomes of the testing can be registered and shown on mobile apps as “passes” for the person’s mobility permissions:
Table 1. Mobility Decisions Based Upon Testing and Close Contact
We should conduct regular Ab testing for the entire population. The benefits of such a scheme of testing include:
1) Accurate information of the speed and degree to which the populations have been infected and have developed immunity.
2) Capture suspect cases, which are tested positive for IgM but negative for IgG.
3) Comfort those who have already gained post-infection immunity (with IgG Positive) and encourage them to work, live and donate plasma.
4) Reduce future workload of close contact tracing as increasing number of the contacts gaining post-infection immunity and showing dark green.
Another issue is to differentiate between asymptomatic coronavirus carriers and the cases, those who have developed post-infection immunity in regular Ab testing in the population. It is important to examine whether serum IgG titers between them are different in testing as some authors reported in previous SARS studies and whether quantitative or semi-quantitative IgG testing (high-titer and low-titer) can be put in place accordingly.
3. Mop-Up and Hot Spotting
Each and every suspected case and close contact must be checked and tested!
3.1 Examine Suspected Cases
Incentive and convenience must be provided to encourage those who manifest Covid-19-like symptoms to come forward and request for testing, quarantine or hospitalization. To encourage citizens’ participation, the costs of testing, quarantine and hospitalization must be covered by public funds and their jobs should be preserved wherever possible through public assistance to their employers.
3.2 Contact Tracing
Contact tracing organizations need to be established at various levels, with legal power for investigation and data systems to support their operations. The contact tracing team should be required to work with every person who has been tested positive for coronavirus. Close contacts in the past two weeks have to be traced, examined and tested. If positive cases are identified in these contacts, a cascade of contact tracing should be conducted.
We will encounter cases of people, who have already recovered and therefore, both coronavirus nucleic acids testing antibody testing should be used. Additionally, Ab testing, especially IgM testing, can be used to supplement RNA testing due to difficulties in obtaining the viruses, which are not always present in nasopharyngeal region.
Coronavirus-specific IgM becomes positive a week after infection. Therefore, a person who had close contact with an infected case but shows negative IgM a week after the date of close contact should be allowed to go back to work or to be released from quarantine.
3.3 Body Temperature Measuring in Public Places
To reduce virus spread in public places and identify suspected sources of infection, body temperature must be measured before entering public places, in addition to checking the color of the pass on each and every person’s mobile device.
3.4 Regular Testing Requirements in Workplace
In addition to body temperature measuring in workplace, employers should be required to renewal their employees’ mobility passes on regular basis through Ab testing.
4. Quarantine and Treatment
All those, who are suspected to be contagious, should be placed in quarantine or hospitalized with YELLOW or RED pass in their mobile app. Quarantine laws should be established so that designated forces get to randomly check pass in public space and employers are required to repeat pass-checking on regular basis. If they violate quarantine rules before their pass turns to GREEN, a significant penalty must be awarded for each violation. On the other hand, incentives such as costs of quarantine or/and hospital stay and living expenses should be provided so that incidents of violation can be minimized.
The Key Pillars
The four critical measures described in this proposal require support from legal, organizational, technological and economic aspects.
1. Contact Tracing Organizations
We need organizations of case workers to work with everyone who has been tested positive for coronavirus, to trace their close contacts, the public spaces they visited and the public transportation they’ve used in at least the past two weeks. These organizations will be managed by local governments under CDC’s guidance. The case workers can be hired from the growing number of unemployed Americans and trained to conduct contact tracing. It is crucial that these organizations should have legal backing and enough technological support to conduct contact tracing effectively.
2. Data Platforms and Apps
Centralized data platforms should be developed for efficient data registration, dispensing and utilization. Mobile apps should be used to issue and renew pass of colors. Green passes must be required for travel and work during this recovery period.
3. Rules and Laws for Information Acquisition and Quarantine Enforcement
A new set of rules and laws need to be established and enforced to support pandemic monitoring, contact tracing, quarantine enforcement and, of course, privacy protection. Penalties must be given for each and every violation.
4. Free Testing and Free Treatment
We would like to propose that financial assistance such as costs for testing, quarantine, hospitalization, and cost of living due to quarantine and hospitalization should be covered by governments. Such assistance provides citizens adequate incentive to follow quarantine rules.
In summary, the proposed proactive approach of testing for coronavirus, contact tracing and quarantine enforcement will allows us to keep the pandemic under control while regions and the entire nation resume normal living and work and American economy revive, without the need to attain “herd immunity” as precondition. Should any region fails in implementing the approach, we simply send it back to isolation and start all over again.
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