Many countries have reacted to the COVID-19 pandemic by locking down whole economies. While this blunt approach has successfully reduced transmission of the virus, it has also starved economies, making the medicine often as bad or worse than the ailment. A more-tailored risk-based approach, as has been used by countries that have successfully controlled their outbreaks, would curtail transmission by the most likely sources, while allowing for more individual movement by the least likely transmitters, providing for the safest reopening of the economy.
We undertook an extensive review of evidence regarding approaches to (a) limiting the spread of SARS-CoV2, the virus that causes COVID-19; (b) reducing mortality from COVID-19; (c) enabling the maintenance of supply chains and essential services; (d) enabling more widespread opening of the economy once effective measures have been put in place to reduce transmission and contain local outbreaks.
Based on this review, we identified several actions that, if taken together, form a coherent and effective approach. Some of these actions are best undertaken by the private sector. Some require government action—though in most cases that action is at a relatively decentralized level: town, county, city, or other local jurisdiction, rather than state or federal. Overall, they can be construed as a public-private partnership.
A. Measures to identify the scale of the infection, including hotspots, and contain it
The following three steps are intended to discover how widespread COVID-19 is in a jurisdiction, identify emerging virus hotspots or “clusters”, contain those clusters and reduce transmission generally. These steps should be implemented as soon as possible.
1. Undertake population screening for the virus (SARS-CoV2), as well as antibodies to the virus, in order to locate clusters of current and past infection.
2. Simultaneously undertake targeted testing and contact tracing, both manually and through the use of contact tracing apps, in order to identify as far as possible all those who have the virus.
3. Incentivize full isolation for all who test positive for the virus and anyone identified as at risk due to contact with an infected person, until they are able to have a test. Retest individuals for both virus and antibodies after 2 weeks if non- symptomatic at that time.
B. Support the development of risk-based systems that will enable individuals and companies to engage in an increasingly wide range of economic and social activities
The next four steps are intended to enable individuals and companies to understand better the infection risks associated with particular actions and interactions, and to set rules that appropriately limit those risks.
By taking these steps, it should be possible to implement a phased reopening of businesses and other institutions, and relax stay-at-home requirements, while maintaining appropriate mitigation measures.
The objective is to replace a system that punishes the vast majority of people and businesses with one that requires only those who are infected or likely infected to self- isolate. Those least likely to be infected are able return to work and more normal activities in relative safety.
4. Support the development of an infection-risk based Red-Amber-Green (RAG) CV19 status system for individuals, activities and jurisdictions, which can be used to determine who can and cannot do what, where.
5. Support the use of privacy- and-autonomy-protecting authenticated CV19 status app(s) for access to activities. The purpose of these apps is to enable individuals voluntarily to share their status with others, in order to ensure both parties are able to take appropriate measures to limit risk. The apps could also be tied to a contact tracing system, thereby improving the effectiveness of that system.
6. For many activities in many places, it will likely be necessary to use masks and other personal protective equipment (PPE). Given the current lack of adequate PPE supply, it is important that any unnecessary barriers to production and distribution be removed. In particular, current federal regulations must be relaxed.
7. Businesses should be encouraged to develop best practices for limiting exposure to CV19, which might be formalized as “CV19 standards”. Given concerns about liability for negligence resulting from exposure of staff and customers, Congress should consider limiting liability for businesses that adopt these standards.
C. Encourage the development of effective therapies and vaccines
The final steps in the plan relate to the development of therapies and vaccines. It is expected that the former will reduce the severity of COVID-19 and lower the mortality rate. It is hoped that the latter will enable widespread immunity and hence return to normalcy.
8. Incentivize the rapid development of safe and effective treatments and vaccines. New drugs and vaccines usually take months or even years to test in trials involving thousands of people. Since time is of the essence, new, more efficient solutions are needed—and to a considerable degree are being applied. This has required the relaxation of some regulations.
9. Once effective treatments are available at sufficient scale, so that the case fatality rate is substantially reduced, it may be possible to adjust the risk- proportionate restrictions on individuals, activities and jurisdictions. Given that the main justification for the restrictions was the feared high rates of hospitalization and fatality, which threatened to overwhelm healthcare systems, it makes sense that as effective therapies arrive, the curve will automatically be flattened, so the restrictions can be removed.
10. Once an effective and safe vaccine is available and deemed to be “preventative,” it will be made freely available to all. Most restrictions on vaccinated individuals will be removed. Once a sufficient proportion of the population has immunity, either from the vaccine or having COVID-19, the remaining restrictions may be removed.
Actions 1 through 7 can and should be implemented more-or-less simultaneously. This would enable the rapid removal of many restrictions on movement, while simultaneously protecting the most vulnerable and containing the spread of the virus. It is not necessary to test everyone before removing many of these restrictions.
These measures offer an adaptable range of options, and no one approach will work everywhere. Rural areas may not need to use as many tools to reduce risk as urban areas do, and communities with more vulnerable populations, such as more retirees, may need to take different measures from college towns. In all cases, more data-driven approaches based on track and trace are desirable.
For similar reasons, some jurisdictions will be able to open up more rapidly than others, based on the assessment of local risk factors. Other jurisdictions may have to remain subject to more restrictions for a while longer.