https://www.bloomberg.com/news/articles/2020-03-25/what-would-it-take-to-lift-coronavirus-restrictions-experts-weigh-in
U.S. coronavirus infections have passed 50,000. The death toll, while still well below the worst-hit countries, is expected to rise. Personal protective gear has run short at hospitals, and many patients with mild symptoms still can't get tested.
The U.S. isn't yet close to having its Covid-19 outbreak under control. But with markets in turmoil and jobs being lost across the country, President Donald Trump has begun laying the groundwork for state and local governments to lift personal restrictions and shutdowns of businesses that have devastated local economies.
"THE CURE CANNOT BE WORSE (by far) THAN THE PROBLEM!" Trump tweeted Tuesday. In a Fox News town hall appearance later that day, Trump suggested the country might reopen by mid-April. "I would love to have the country opened up and just raring to go by Easter," Trump said.
"We need to absorb the pain now," says Larry W. Chang, an infectious disease doctor and researcher at Johns Hopkins University School of Medicine. "If you lift restrictions early, the number of infected people will skyrocket. Hospitals will be overwhelmed." That might cause state and local governments to impose even more draconian restrictions, extending economic damage.
Many medical experts think the U.S. won't be ready to lift restrictions for weeks or months. "Before considering big changes to social distancing measures now, we should as quickly as possible get to strongest possible position for COVID response – we're no where near that now," Tom Inglesby, director of the Johns Hopkins Center for Health Security, said on Twitter Monday.
But even the most hard-core epidemiologists don't want to sit inside forever.
The global pandemic is still new and poorly understood, with debates about how deadly it is, how many people are infected, and who's most at risk. "We are flying the airplane while we are building it," said Gregory Poland, who heads the vaccine research group at the Mayo Clinic in Rochester, Minnesota.
Bloomberg News spoke to several experts on public health and outbreaks about what would need to happen for the U.S. to start easing some restrictions, what it would take for people to get back to work, and what the consequences of getting it wrong could be.
Buy Time
Authorities can't start lifting restrictions until the outbreak is better under control. Even with reduced transmission as people stay home, it will likely be many weeks, or more likely months, before that happens. That means, in the short term, harsher measures.
"You shut everything down now except for essential services," said Poland. "The safest thing to do is watch and wait until there are either no or very few additional cases," and ideally a few weeks after that. Then governments could start lifting restrictions, with younger and healthier people going first.
In Wuhan, China, where much more restrictive measures on personal movement were implemented, authorities are only now starting to re-open the city — two full months after it was sealed off from the world.
So far in the U.S. some states have enacted heavy restrictions, closing businesses and telling people not to leave their homes, and others haven't. A more complete U.S. shutdown, even a few weeks, could buy time to learn more about stopping the virus, either with drugs under testing or with better knowledge about who's most at risk.
Lots of Testing
Countries like South Korea have done a much better job at identifying and isolating cases early on, and tracing all their contacts. As a result, the restrictions they've implemented have been far looser. If the U.S. wants people back to work, it needs to find out who's sick and who they might have spread the coronavirus to, said Saad Omer, director of the Yale Institute for Global Health.
"This is how you stamp out these fires, and we haven't been doing this at all," said Omer.
To do that, the U.S. has to test people. Lots of people. But at present, limits on the availability of tests have meant that mostly moderate-to-severe patients are getting diagnosed, while milder cases are told to stay home.
"We need to take the magnitude of this seriously if we are serious about saving the economy," Omer said. "There are no shortcuts."
That means everything from drive-through testing to broad availability at doctors' offices and clinics to test anyone who might have had contact with a Covid-19 patient. It also means getting them the results quickly. A positive test gives mildly ill people more reason to stay home and take precautions, said former Food and Drug Administration Commissioner Scott Gottlieb. "People are much more likely to self isolate with a positive result," Gottlieb said on Twitter Sunday.
To test more, the U.S. also needs to ramp up access to protective gear for doctors and nurses. When ICUs treating desperately ill Covid-19 patients don't have enough masks for their nurses, it's impossible to spare protective equipment for testing patients with minimal symptoms. If the testers can't protect themselves from sick patients, it's harder to get them in the field to do the work. Or they can become vectors of transmission themselves.
Track Cases, Stop Infections
Testing people only matters if you do something about it.
The U.S. will likely need thousands more workers to do the contact tracing, since overwhelmed state and public health agencies don't have enough people to do it on their own.
"We are going to need to hire a new work force to do a lot of these things," says Chang of Hopkins. To stimulate the economy, federal or state governments could hire unemployed workers from hard hit service industries, and shift them into Covid-19 tracking and isolation, he said. Or the National Guard could be called into action to help.
It's also important to stop people from spreading the virus to relatives. Despite all the worry about getting Covid-19 on a subway or at the grocery store, a hallmark of Covid-19 in China and elsewhere is that much of the spread is within families.
"Another thing we need to do is focus on reducing transmission at the household level," said Yale's Omer.
Families who have to deal with an infected relative will need a ready supply of masks, both for patients and designated caregivers, and hotlines they can call for advice on keeping their home disinfected. They may also need places to safely isolate sick loved ones who are ill, but not sick enough to take up a valuable hospital bed.
Find Out Who's Immune
Once a person has been sick with a virus, their immune system remembers it. Antibodies in the blood indicate that a person was previously infected — and is unlikely to get sick again. That can be checked with a blood test.
"If you make effective antibody, you shouldn't get re-infected," said Deborah Birx, a State Department health official who is part of the White House coronavirus task force, said Tuesday.
Epidemiologists believe that there are likely many thousands of Americans who already have been infected with the virus, but don't know it because their symptoms were mild or nonexistent and they were never tested. A reliable blood test would allow doctors to identify people who have been exposed and already have antibodies to the virus, and should be able to safely go back to work or school. This could be particularly helpful for health workers and other front-line responders who face more risk of being exposed.
"As the epidemic proceeds, we will want to do serological tests (by drawing blood) on as many people as possible to identify people who have recovered and are highly likely to be immune," said Nicholas Christakis, a social scientist and physician at Yale University, in a March 19 tweet. "This should be a national priority."
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