Before You Lift the COVID-19 Restrictions…

What needs to get done before the country — and the world — can get back to normal.

As a small-but-vocal (dare I say, “vociferous”) minority of people are protesting around the country to lift the restrictions placed on businesses and schools to protect public health, there is no doubt that more and more political authorities are going to be pressured to “re-open” their jurisdictions and return to “normal.” Before they do so safely, there are certain things that need to be in place. Let me tell you what those are from a public health and epidemiological perspective…

First, let’s define normal.” Normal cannot be a society where going without a paycheck for a couple of weeks causes people to go broke. Normal cannot be a society where the oldest and most fragile are concentrated in places with sub-optimal care. And normal cannot be a place where public health decisions are not made by public health experts in consultation with politicians… Not the other way around.

It is not at all easy to create a vaccine. Look at the things that assail humanity day to day and for which we do not yet have a vaccine. Then look at the vaccines we do have and how effective they are. The influenza vaccine varies in effectiveness from season to season and between age groups. The measles vaccine is very good (about 98% effective), but lies and misinformation have ruined its reputation so much so that we see regular measles epidemics in countries that had allegedly “eliminated” measles.

Then there are vaccines like rabies, whose use needs to be very controlled because they are quite immunogenic, so they are capable of causing injury at a wide scale if used in the general population as a preventative measure. Or vaccines like the Bacillus Calmette-Guerin (BCG) againt tuberculosis which are only used in developing nations and mostly to prevent serious complications (like spinal tuberculosis) of the disease and not the disease itself.

There is also a matter of funding. In the early 2000s, Dr. Peter Hotez at the Baylor College of Medicine almost had a vaccine ready to go against coronavirus. But the coronavirus that caused SARS in 2002–2004 disappeared, and the funding for his vaccine dried up. We would probably have a vaccine this summer if that vaccine had been fully funded to development and trials.

Exactly how long it will take to get a vaccine for the current virus (NCoV-2) is a matter of much debate. Some say we’ll have one by this fall. Others say it will be one year to 36 months. Others say it will be years. Whatever the time is, there is no doubt that this may be the Manhattan Project of our day, something that needs to be fully funded and for which the best and brightest minds must work together instead of competing with each other.

Once a viable vaccine is ready, then we’ll have to figure out who gets it first. Going by the current epidemiology — which may change as the pandemic develops — we might give it to people over the age of 65 first, then those with preexisting conditions that put them at risk for complications, then everyone else. If we find out that children are “super spreaders,” then we include them in the initial wave of vaccinations. And then, of course, there is the matter of access… How do we help developing nations and marginalized groups in developed nations have access to the vaccine?

Respiratory diseases are bad on the elderly and those with preexisting conditions. In the United States, we tend to concentrate those people in skilled nursing facilities because their families generally lack the funds or ability to take care of them at home. Those skilled nursing facilities compete for clients, and, in doing so, they cut costs as much as they can to offer bottom-dollar deals to people who are looking for a place where their loved ones can be cared for.

Bottom-dollar also means low quality, unfortunately. You can only cut costs so much before they start cutting into the quality of the service being provided. That’s capitalism for you, and it’s something that won’t change any time soon without specific actions by the people and the government. The people need to demand better regulation of these facilities to ensure a basic level of quality, and the government needs to institute those demands and bring everyone up to an equitable level.

Part of that effort will need to be sure that the staff of the facility know their stuff. They need to know infection control, cleaning and nursing. It is not enough that they know how to care for someone medically. They need to know that the virus is transmitted by droplets, and that the droplets go a certain distance. They need to know that the virus lands on surfaces and lives on them for a certain time, and how to clean, clean, clean.

Here is the controversial part of my plan: Turn skilled nursing facilities into “islands.” By this, I mean that no one goes in and no one goes out. The staff stay inside with their clients, and everything is delivered to them until a viable vaccine is available. If someone is shipped out of facility to go to the hospital and released, they are released to a field nursing facility created for such a thing. If someone needs nursing care, they go to the same field nursing facility. But what if there is an outbreak already happening?

If there is an outbreak under way at a facility, the residents are moved out to different field centers where they are taken care of by a specific team that shall not mix. The facility is then cleaned out completely and residents are brought in one by one after a 21-day quarantine period. (Yes, 14 days is showing not to be enough.) This assumes that an excellent test is available to detect those who are infected, and we do not allow infected/infectious people back into the facility (be they staff or resident).

Much of the epidemiology around this coronavirus (NCoV-2) signals that children are not being affected by the virus like older adults are. Because of gaps in testing, we simply don’t know if they are infected and pass the virus around, or they are not infected at all. If this is like other viruses, then it is infecting them but not making them sick. They are then passing it among themselves and then to the rest of us.

Until we get an effective and efficacious vaccine (the two terms are different things when it comes to vaccines), school should be online. When done right, online education can be quite successful at teaching children the basics. However, this leaves us with two gaps that need to be addressed. First, the lack of access to technology. For this, we partner with telecommunications and internet service providers. We make sure that the whole country is blanketed with reliable wifi and 4G and 5G wireless internet. We also make sure each child has a reliable device to connect to their online learning.

The second gap is children who are too young for school and/or parents who cannot stay home to look after children learning online. For this, we decentralize learning. We’re talking small groups (no more than ten children) in places where families can drop off the kids and go to work. Places like community centers with separate rooms, homes with space for the kids, and parks and other facilities (like movie theaters) would be recruited to serve as classrooms. Those places would still be subject to some infection spreading, but you limit that by keeping the number of children low.

For community interactions, dedicated teams would spray down playgrounds and other places where kids go play. Those teams would also be empowered to deliver social distancing messages to people they see congregating more than ten at a time. And they would have the ability to notify law enforcement of anyone not following social distancing rules.

Hopefully, most companies in the United States have figured out how to function with remote employees. Call centers can be remote. Customer service centers can be remote. Jobs that happen outside, like public works and landscaping can continue unabated because fresh air dilutes the concentration of the virus and everyone is expected to social distance and wear masks.

Basically, if you can do your job while not being within six feet of anyone for more than 5 to 10 minutes, the job opens and keeps a close eye on crowding and infection control. If this cannot be achieved, then we (public health) work with them (the jobs) to figure out the best way to do it. If it cannot be done, then workers remain on leave (with proper basic income) until a vaccine can be developed or their work can be re-imagined or re-engineered to minimize the risk of contagion.

If there is an essential business category out there, grocery stores are probably it. It is simply impossible to maintain any sense of normalcy if you can’t buy essential things to eat. (We’ve certainly moved away from Victory Gardens, haven’t we?) So grocery stores can do one of two things. First, they can re-design their stores to maximize social distancing as people go in and buy their food, or they can move to an all-delivery or curbside pick-up system. Both have their pros and cons.

But what about retail? We need to buy clothes, shoes, and other household items. Certainly, people in the United States are steeped in consumerism, buying more and more things without really needing them. So how do we return to that? Online businesses are one way, shipping everything to homes around the country. (This keeps shipping company employees working, too!) Another way is to re-design stores, or designate specific hours for specific people to go shopping. (One grocery story is asking people to visit on certain dates based on the first letter of their last name.)

Then there are the other things we need, like refrigerators, stoves, and washer/dryers. Can you really buy one online and be okay with it? Well, some people can. Others want to see it in person before pulling the trigger on such an expensive buy. This is going to require a lot of ingenuity. There are some software programs that can show you what something in your house will look like with virtual reality, or you can send a picture of where that something will go and the company will get back to you with a mock-up of what it will look like.

Again, technology can be our friend here.

Did you know that there are over 3,000 counties in the United States, and that a great many of them do not have an epidemiologist on staff? There are entire counties without someone trained in systematically collecting, analyzing and distributing the data in a way that matters, in a way that leads to action. That needs to change.

While there may not be enough epidemiologists to go around, there are enough people with the education (usually a master’s degree in public health) to learn epidemiology quickly. These folks already have some foundations of epidemiology such as statistics, biology and data analysis. They just need to be pushed a little further toward understanding the diseases and conditions that affect the people, understanding the biases and confounders that may lead to the observations they make, and understand how to communicate data and evidence effectively.

It’s not a big ask, but it will be quite the undertaking to give each county at least one epidemiologist who can work with them. This will help understand the data at a local level rather than relying on the state or federal authorities to update them. Eventually, hopefully, this will lead to quicker action at the local level.

Of course, all of this depends on available testing. As I’m writing this on Monday, April 27, 2020, only about 5 million people have been tested in the United States. That leaves more than 320 million people untested. We simply don’t know right now how many of those 320 million are carrying the virus, continuing the chain of infection. This makes us vulnerable to a resurgence of the virus if social distancing restrictions are eased.

Then there is the matter of which test to use. Do we test for the virus? If someone is not showing any symptoms, do we test them? Or do we only test those who are sick? If we test everyone, do we also test for antibodies to know who has been exposed? And what do antibody tests tell us about immunity?

Those are many questions that are yet to be answered. And that is why we are not going to see a return to any kind of normalcy any time soon, I’m afraid.

Even if we gain the ability to test everyone, we are going to need a very robust — very reliable — way to trace people’s contacts, and for those contacts to follow our recommendations to self-quarantine. That means that some people will likely have to extend the period of time that they are confined to their home. Others will be allowed out, only to go back in if they are close contacts of a known case. And others will not allow us — public health — to trace their steps back to identify their contacts.

Most people will be reasonable with this, though. Most people have been reasonable, but there is growing unease of the way the response has gone. I can only foresee more and more folks not wanting to be tracked, or told what to do if they were in contact with a sick person. At least that will be the case in parts of the United States and not in parts or regions (or countries) where the culture is more collectivist.

There is still a lot of work to be done. If we get a vaccine any time in 2021, it will be a record for a vaccine going from zero to widely available. Social distancing restrictions will have to remain in place in some form for the foreseeable future. Maybe it’s just wearing masks in public. Maybe it’s outright closures of entire regions again if there is a resurgence.

The main thing is that we need to be slow and deliberate in doing all of this. We cannot do it based on gut feelings and political gains. It needs to be done based on data and evidence. The greatest minds in virology, epidemiology, sociology, business and public policy — to name a few — need to come together and formulate plans that are specific to localities. As we have learned, the United States is like 50 different countries, and the differences within the states can be stark. All of that, and so much more, needs to be taken into consideration before we can say that we are back.

But we will be back.

We will.

René F. Najera, MPH, DrPH, is a doctor of public health, an epidemiologist, amateur photographer, running/cycling/swimming enthusiast, father, and “all around great guy.” You can find him working as an epidemiologist a local health department in Virginia, grabbing tacos at your local taquería, or on the campus of the best school of public health in the world where he is an associate in the Epidemiology department. All the opinions in this blog post are those of Dr. Najera and do not necessarily represent those of his employers, friends, family or acquaintances.

Doctor of Public Health in Epidemiology. Associate at JHSPH. Adjunct at George Mason Univ. Epidemiologist at a large County Health Department. Father. Husband.

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