This series of articles is about the COVID-19 pandemic, but specifically deals with social distancing: what is it, why do we need it, how to do it right. It is written by Edison Liu and Jill Goldthwait who are both medical professionals who have broad governmental, scientific, and management experience. Goldthwait is an R.N. who has served in the Maine State Senate for 8 years and is currently serving in local government, Liu is an M.D. and is the President and CEO of The Jackson Laboratory. He previously led the scientific response for the country of Singapore for the SARS crisis in 2003. The opinions expressed are those of the authors and do not reflect policies or positions of The Jackson Laboratory or the Town of Bar Harbor.
Now that we have social distancing policies and protocols in place, how long will it be before they can be relaxed? Using China and South Korea as our guides, stringent quarantine and isolation procedures were required for over two months before the restrictions could be relaxed. So, if we mark the initiation of social distancing policies to the March 13th declaration of National Emergency by President Trump, then based on the experience from Asia, it would be in late May or early June before the U.S. would conceivably emerge from our state of shelter-in-place. The most recent mathematical models of the COVID-19 pandemic in the U.S. (https://covid19.healthdata.org/projections) show that, if social distancing policies can be maintained, the “surge” in U.S. cases that is beginning now, will peak the week of April 15 and disappear in early to mid-June. Indeed, the most recent Stay at Home Mandate issued by Governor Janet Mills that covers April 2 through April 30 was optimally timed to reduce the impact of the “surge.” This is especially important to preserve the capabilities of Maine’s hospitals. In a small remote state, our hospitals are our lifeboats.
How do we know when the coast is clear? Theoretically, it should be when there are no new cases in the country. In the SARS epidemic in 2003, Singapore waited for at least ten days after the last reported case before opening the city state to make sure that no one was incubating the virus during the lull. For a pandemic, where the total elimination of the virus is unlikely, this scenario may not be feasible. In 1918, premature cessation of social isolation policies in St. Louis resulted in a rebound of the epidemic. Does this mean we will never be able to drop our social isolation policies? No. This scenario of continued economic and social disruption is not inevitable. If we are smart, if we have the will, and if we use our advanced technologies which were not even conceived of in 1918, we will not need another lockdown. We just have to be more cautious and much better organized.
Let’s consider what Singapore is currently doing that may be a model. After their “surge,” Singapore settled on social distancing “light”: large groups are not to congregate, shopping malls close at 8PM, no nightclubs are open, people are instructed to wash hands and wear masks, but local commerce continues, although at a reduced level. In fact, Singapore has used a sliding scale of actions called Disease Outbreak Response System Condition’ (DORSCON) to match the stringency of restrictions with the severity of the pandemic (https://www.gov.sg/article/what-do-the-different-dorscon-levels-mean). These were publically broadcasted early in the pandemic so that the populace knew what to expect. This works in Singapore because they quickly identify and isolate potentially infected individuals: individuals monitor their own temperature and are tested immediately when symptoms arise. Those people who test positive are then isolated. This “test, treat, and track” strategy provides precision of action to minimize societal disruption and has also been successfully implemented by Taiwan and South Korea.
What will we need to do differently that will allow commerce to proceed while still preventing the spread of COVID-19? There are two areas of action: mass testing for COVID-19 and enhanced personal protection including the widespread wearing of masks. First, all individuals with any respiratory symptoms must be tested, as should individuals who are asymptomatic but who may have been in contact with an infected person. This must be followed by quick contact tracing and isolation of exposed individuals. The purpose is to segregate infected individuals from the majority who are unaffected.
Second, the use of personal protective items needs to be expanded. Everyone should be wearing a mask whenever they may encounter other people and should be washing their hands at least ten times a day. The rationale for washing of hands is obvious, but let’s be clear, wearing masks protects the public from the wearer, but not the wearer from infected individuals. Still, despite the imperfect nature of standard surgical-type masks, studies suggest they can reduce the rate of viral infections in a community. For COVID-19, infected individuals may show no symptoms but can still transmit the disease. Widespread use of masks will reduce the chances of spreading the disease by asymptomatic, but infected people. In a pandemic no single action is sufficient to blunt the course of spread. Only when several actions are put together and practiced by the majority of the population can we be successful.
These recommendations sound different and even contrary to what we have heard from the U.S. CDC and some state health agencies. Previously, only those individuals who were very sick or were healthcare workers with symptoms could be tested, and wearing a mask unless you are ill was not recommended. In all fairness, these earlier recommendations were based on information that was available then and calibrated so as to limit the tests and the masks (personal protective equipment or PPEs) to critical medical personnel. They were, in large part, based on resource limitations and not optimal action. While this is understandable, the message was confusing and led to the general sense that there is no need to test widely, and no need to wear protective masks in public. Fortunately, the original recommendations are being reversed as tests and masks are becoming available.
The truth is that there is no magic bullet and there are no quick fixes. But there is a pathway forward and there will be an end to this crisis. Social and physical distancing are effective, though disruptive, measures that need to be implemented until a vaccine can be developed and deployed, and anti-virals are available. We need to be resolute and patient. In the end, we shall overcome.
- Visualization tool:https://covid19.healthdata.org/projections
- Paper: http://www.healthdata.org/research-article/forecasting-covid-19-impact-hospital-bed-days-icu-days-ventilator-days-and-deaths
- Jefferson T, Del Mar C, Dooley L, et al. Physical interventions to interrupt or reduce the spread of respiratory viruses: systematic review. BMJ. 2009;339:b3675. Published 2009 Sep 21