COVID-19 PHASE II DECONFINEMENT RULES

Source: American Enterprise Institute (Authors: Scott Gottlieb, Mark McClellan, Lauren Silvis, Caitlin Rivers and Crystal Watson).

Individual countries can move to Phase II when they are able to safely diagnose, treat, and isolate COVID-19 cases and their contacts. During phase II, schools and businesses can reopen, and much of normal life can begin to resume in a phased approach. However, some physical distancing measures and limitations on gatherings will still need to be in place to prevent transmission from accelerating again. For older adults (those over age 60), those with underlying health conditions, and other populations at heightened risk from COVID-19, continuing to limit time in the community will be important.

Public hygiene will be sharply improved, and deep cleanings on shared spaces should become more routine. Shared surfaces will be more frequently sanitized, among other measures. In addition to case-based interventions that more actively identify and isolate people with the disease and their contacts, the public will initially be asked to limit gatherings, and people will initially be asked to wear fabric nonmedical face masks while in the community to reduce their risk of asymptomatic spread. Those who are sick will be asked to stay home and seek testing for COVID-19. Testing should become more widespread and routine as point-of-care diagnostics are fully deployed in doctors’ offices.

Trigger to Move to Phase II. 

To guard against the risk that large outbreaks or epidemic spread could reignite , the trigger for a move to Phase II should be when a country reports a sustained reduction in cases for at least 14 days (i.e., one incubation period); and local hospitals are safely able to treat all patients requiring hospitalization without resorting to crisis standards of care; and the capacity exists in the country to test all people with COVID-19 symptoms, along with the country capacity to conduct active monitoring of all confirmed cases and their contacts.

A country can safely proceed to Phase II when it has achieved all the following:

• A sustained reduction in cases for at least 14 days,
• Hospitals in the country are safely able to treat all patients requiring hospitalization without resorting to crisis standards of care
• The country is able to test all people with COVID-19 symptoms, and
• The country is able to conduct active monitoring of confirmed cases and their contacts.

In Phase II , the majority of schools, universities, and businesses can reopen. Teleworking should continue where convenient; social gatherings should continue to be limited to fewer than 50 people wherever possible. Other local restrictions should be considered, such as those that limit people from congregating in close proximity.

High-contact settings such as schools should continue to review and implement physical distancing measures with guidance from health authorities and input from local officials. Health officials should recommend increased social hygiene measures and cleaning of shared surfaces.

For older adults (those over 60 years old), those with underlying health conditions, and other populations at heightened risk from COVID-19, it should still be recommended that they limit time in the community during this Phase II . This recommendation may change if an effective therapeutic becomes available.

Goals of Phase II

The goals of Phase II are to:

1. Lift strict physical distancing measures in a concerted and careful fashion,
2. Allow the vast majority of businesses and schools to open, and
3. Continue to control transmission in order to avoid a reversal ack to Phase I.

The adoption of these Phase II measures will require a careful balance. Implementation of these measures will need to be reevaluated based on available surveillance data, and will need to be ready to adjust the approach over time according to the epidemiology of local, national, and global spread.

Thresholds for Action

Trigger to Lift Physical Distancing Measures 

Once the criteria for the transition from Phase I to Phase II have been met and we begin to move away from the “slow the spread” period,  national leaders  should begin an incremental easing of physical distancing measures. This should be done gradually and should be paired with increased surveillance for new cases. National officials should make decisions about the selection and timing of restrictions to lift based on their local contexts. Restrictions should be eased gradually, with sufficient time between each adjustment to carefully monitor for resurgence of transmission.

Steps Required in Phase II

Implement Case-Based Interventions. Using the public-health capacities developed in Phase I, every confirmed case should be isolated either at home, in a hospital, or (voluntarily) in a local isolation facility for at least seven days, or according to the latest health authorities guidance. People awaiting test results should be advised to quarantine until their results are returned.

The close contacts of confirmed cases should be traced and placed under home or central quarantine, with active daily monitoring for at least 14 days, or according to the latest health authorities guidance. Diagnostic tests should be immediately administered to any close contacts who develop symptoms.

Begin to Relax Physical Distancing Measures. General physical distancing precautions should still be the norm during Phase II, including teleworking (as much as possible), maintaining hand hygiene and respiratory etiquette, wearing a mask in public, regularly disinfecting high-touch surfaces, and initially limiting social gatherings to fewer than 50 people. These recommendations should be augmented through technological solutions to understand physical distancing behaviors and adjust risk messaging as needed. This should be accomplished through partnerships with the private sector, with careful attention paid to preserving privacy and avoiding coercive means to encourage compliance.

As children return to school and daycare (i.e., high-contact settings) and people return to high-density workplaces, leaders of these organizations should continue to review and implement physical distancing measures based on guidance from the health authorities for schools and businesses.

Special Care for Vulnerable Populations. While easing of physical distancing is taking place, highly vulnerable populations, such as individuals older than age 60 and those with compromised immune systems or compromised lung and heart function, should continue to engage in physical distancing as much as possible until a vaccine is available, an effective treatment is available, or there is no longer community transmission. Special attention should be paid to long-term-care facilities and nursing homes. These facilities will need to maintain high levels of infection prevention and control efforts and limit visitors to prevent outbreaks.

If a treatment or prophylactic, such as a monoclonal antibody, becomes available, high-risk and vulnerable populations should be prioritized to receive it, to both protect those individuals and reduce the likelihood of an increase in severe illnesses and additional patient surge in hospital intensive care units (ICUs).

Accelerate the Development of Therapeutics. Therapeutics play an important role in caring for those who are sick. Accelerating the research, development, production, and distribution of safe and effective therapeutics is a top priority. With effective development strategies and early investments in commercial-scale manufacturing, a successful therapeutic could receive emergency use authorization or approval as early as the summer or fall, if trials demonstrate that it meets either standard.

Therapeutics can serve a number of roles. First, they can serve as a prophylaxis to help prevent infection in those at greatest risk of infection, such as front-line health care workers, or those at risk of bad outcomes, such as individuals with preexisting health conditions and those who are immunocompromised. Such a treatment could include a recombinant antibody that can target the virus surface antigens. As an example, researchers successfully developed such a therapeutic against Ebola. These antibody drugs can also be used to treat early infection or as a postexposure prophylaxis.

Other therapeutics might include antiviral drugs that target features of how the virus replicates. These drugs can be used to treat people who are critically ill or earlier in the course of disease for those at risk of developing a complication. Antiviral drugs can also be used as postexposure prophylaxis, depending on their safety profile. Postexposure prophylaxis and products that shorten the duration and intensity of viral shedding may affect the effective reproduction number only modestly. In addition, immune-modulating treatments may prove to be helpful in mitigating severe lung complications in some patients. A number of promising drugs are in early and mid-stage development.

At a minimum, the optimal profile for a therapeutic that will affect the risk from future spread is one that meaningfully reduces the risk of death or severe disease and perhaps prevents the onset of symptoms or progression to severe disease in those exposed. Oral administration at the outpatient level would be ideal, but alternative administration requirements (e.g., infusion and jet injections) could also be scaled, with sufficient planning.

While private industry has already organized a large task force to share information and capabilities to rapidly advance promising therapies, we need a commensurate focus by health agencies to make sure the best possible resources are brought to this mission. Health  agencies should join organized efforts already underway in the private sector.

Identify Those Who Are Immune. Serology is a method used to identify evidence of immunity in someone who has recovered from infection. With accurate and widely available serological testing, we can identify people who are immune and therefore no longer vulnerable to infection. While we need to better understand the strength of the immune response in mild cases and how long people remain immune from reinfection, we know there is a period where most people will have sufficient antibodies to offer protection. People who are immune could:

1. Return to work,
2. Serve in high-risk roles such as those at the front lines of the health care system, and
3. Serve in roles that support community functioning for people who are still physically distancing (e.g., the elderly who continue to quarantine at home).

To use serology in this way, serological assays are needed and should be widely available, accurate, rapid, and low cost. Such assays have already been developed by researchers, but they have not yet been fully validated and are not available at scale.