It’s dangerous to reopen too soon. So when is it time for states to relax their Covid-19 restrictions?
President Donald Trump has been cheerleading states that are relaxing restrictions in the Covid-19 pandemic and encouraging protests in states that aren’t. At the same time, states are struggling to meet the White House’s guidelines for reopening their economies.
This has proven deeply frustrating for some lawmakers. “My state has no clue how to implement and pay for that system without help from the federal government,” Sen. Chris Murphy (D-CT) told members of the White House Covid-19 task force during a Senate Health Committee hearing Tuesday. “You work for a president who is frankly undermining our efforts to comply with the guidance you’ve given us, and the guidance you have provided is criminally vague.”
Similarly, Virginia Gov. Ralph Northam (D) told the Washington Post that President Trump held a conference call with governors emphasizing that Covid-19 cases need to decline before states can relax only to tweet “LIBERATE VIRGINIA!” two days later.
“Unfortunately, we’ve been receiving mixed messages from Washington,” Northam said.
The Centers for Disease Control and Prevention has prepared a more detailed set of instructions for states than what the White House has provided. The Associated Press obtained a 63-page draft that lays out specifics for reopening places like child care centers, mass transit, and businesses.
But the White House told CDC officials the guidance “would never see the light of day,” AP reports, and that it would not follow that guidance. CDC Director Robert Redfield said more guidance would be made available to states soon, pending review.
One of the central problems for states is the federal government is still struggling to define what counts as safe, let alone help states meet those targets. Meanwhile, some jurisdictions are plowing ahead with plans to relax and reopen their economies while failing to meet even the few standards available. States like California and New York have also established their own benchmarks.
But the lack of clear and consistent goalposts means that, even in the most ideal scenario, cities and states risk a resurgence of cases by relaxing restrictions. And that could end up making the situation worse in the short and long term.
Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, told the Senate Committee on Tuesday he was concerned that states are starting to disregard criteria in the White House’s guidelines he helped develop for when it is safe to relax pandemic control measures.
“If that occurs, there is a real risk that you will trigger an outbreak that you may not be able to control,” he said
Many health officials agree broadly on the elements that need to be in place. Testing vastly more people for Covid-19 has to be the centerpiece of any path to reopening. Contact tracing, the ability to care for infected patients, a declining case count, and some ongoing social distancing are also key components of plans to get people back to work. Most plans also call for a gradual relaxation, proceeding in phases with their own checkpoints.
But the different guidance documents put out by the federal government and some states have proven frustratingly thin on details. And with a persistent shortage of tests, personal protective equipment, and funding, some parts of the country don’t have the resources they need to even assess whether it’s safe to relax.
What are the benchmarks for reopening the economy?
There are several key elements that experts agree have to be in place to start pulling back on blanket stay-at-home orders and non-essential business closures. But some of the guidance from states of the federal government is vague.
Figuring out who has SARS-CoV-2 is the first step in any plan to reopen the economy. Since Covid-19 can spread from people who don’t have symptoms, sometimes for weeks, testing is critical for identifying the infected. Those with the virus can then be instructed to isolate themselves. Repeat this often enough, and the pandemic will fizzle out.
How many tests are needed? Experts have reached different answers, but almost all agree that the US needs vastly more tests than the 300,000 or so per day being conducted right now. The high-end estimates demand testing almost the entire US population every two weeks plus daily tests for workers on the front lines of the pandemic. That would demand upward of 35 million tests per day across the country.
In the meantime, one heuristic could be the percentage of tests that report back positive. William Hanage, an epidemiologist at Harvard University, told NPR that less than 10 percent of tests for Covid-19 should be positive. If it’s higher than that, it means you aren’t testing enough to stay ahead of the disease.
New York, the current epicenter of the pandemic, is aiming for 30 diagnostic tests per 1,000 people in each region considering reopening. California did not specify a benchmark for testing rates beyond “sufficient testing capacity to meet demand.”
Another key metric for judging whether it’s safe to reopen is the number of people reporting infections; it has to trend downward before states and cities can start letting businesses reopen. The White House guidelines say that new Covid-19 cases have to decline for two weeks straight, and right now, no states meet that threshold. And it’s not just the number of confirmed cases that has to fall; the guidelines also say that reports of influenza-like symptoms also have to fall for two weeks in a row. California and New York both have a similar standard.
New York’s guidelines also call for a decline in deaths and fewer than two new hospitalizations per 100,000 people. For places that had few Covid-19 cases to begin with, they can begin to relax if they never exceeded 15 new hospitalizations a day and five deaths a day over a 14-day period, measured as a three-day rolling average.
Baked into these metrics are monitoring and testing to figure out just how many people have the virus at a given time, and it serves as a proxy for the effectiveness of pandemic control measures like social distancing.
But a decline only tells you about the trajectory of the pandemic. It doesn’t say much about the absolute numbers of people who are infected or the rate of decline. If the infection peak was high and the decline is long and slow, it may not be safe to relax for a long time, lest infections creep back up.
There’s also a time lag between exposures and detected cases since it can take weeks for the infected to show symptoms, so two weeks of falling Covid-19 cases could mask an infection spike in the background.
One of the ways to better use the limited number of Covid-19 tests available is to trace the footsteps of the infected to see who they encountered. Those contacts can then be tested or told to isolate themselves.
The problem is that this kind of detective work requires a lot of labor, or it requires a level of surveillance that may prove uncomfortable or politically untenable. The US would need between 100,000 to 300,000 people trained to perform this work according to researchers at the Johns Hopkins Center for Health Security. It estimated it would cost about $3.6 billion to hire and train these workers.
New York state says it’s aiming to “recruit and train an army of contact tracers,” but that the number needed will be region-specific. The state estimates it will need 30 tracers per 100,000 residents.
Health system capacity
Hospitals and clinics must have enough resources — beds, ICU beds, ventilators, personal protective equipment, staff — to cope with a potential surge in Covid-19 infections. The threat of a shortage in health care capacity is why we had to flatten the curve of cases with measures like social distancing.
The question then is how much headroom is enough. The White House suggests that states have enough capacity when they can treat patients “without crisis care.” That is, there is enough room at normal hospitals and patients don’t have to be treated in makeshift field sites. Those guidelines also call for a “robust testing program” for healthcare workers without defining what counts as “robust.”
Meanwhile, California’s standard is “hospital surge capacity to meet demand,” also not clarifying how much surge capacity is enough.
New York state’s guidelines are more specific. They state that regions must have at least 30 percent of their total hospital beds open as well as 30 percent of intensive care unit beds available before they can begin moving through the phases of relaxing restrictions.
Based on these metrics, New York state reports three regions are on track to proceed toward a phased reopening, where more businesses can reopen and others can open but under restrictions on capacity and requirements for more sanitation.
Meeting the guidelines, whatever they are, won’t mean we’re in the clear
President Trump has made no secret of his desire to end all the measures to control the Covid-19 pandemic and has set their complete removal as his ultimate goal.
“I see the new normal being what it was three months ago,” Trump told representatives from the restaurant and hospitality industries. “I want to go back to where it was, that’s where we’re going to be.”
However, until there’s a vaccine, cure, or widespread immunity, Covid-19 still poses a threat. That means precautions still have to be in place to control the spread of the virus, even as cases decline. People will still have to wear masks. Venues can’t get too crowded. Businesses will run at a diminished capacity. Gatherings will remain small and distant.
Even in places like South Korea and Germany, countries hailed for their responses to the crisis, they have suffered rebounds in infections as they loosened some of their rules around the pandemic. Germany’s Covid-19 cases nearly tripled on May 12 compared to the day before, prompting calls for another lockdown. South Korea reported 34 new infections on May 10, the highest daily case count in a month.
So the world that existed a few months ago is long gone, and it may be much longer before we return to anything like it.
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Author: Umair Irfan