Executive Summary
With the Covid-19 contagion out of control in many regions, a new round of lockdowns are needed in the United States. But they should be much more tailored to local conditions than those imposed in March and April. The focus should be on high-risk venues or scenarios we’ve learned most often lead to transmission and superspreading events (e.g., bars, gyms, concerts, indoor dining, and crowded public transport). Local information on where infections are occurring can be used to identify other specific venues and to tailor the response according to most likely locations of spread.
With Covid-19 cases rising or remaining at extremely high rates in most states, many places in the United States need to immediately reinstate lockdowns to have a chance of regaining control over the epidemic.
We don’t call for new lockdowns lightly and recognize the serious damage they can cause for so many people already under extreme social, economic, and psychological duress. However, the pain millions of Americans are already facing cannot be resolved unless we get the epidemic under control. There are also several ways we can use what we’ve learned in the past few months to implement lockdowns in less restrictive and smarter ways.
The Case for a New Round of Lockdowns
While we have been strong proponents of measures such as better masks for the general population and instituting prevention strategies in workplaces and other venues to get our lives back, we also understand when those measures are not enough, and many places have passed that threshold. The data speaks loudly: More than 35 U.S. states have positivity rates higher than 5%, the World Health Organization’s threshold for reopening, and many are over three times this level; three states (Florida, California, and Texas) reported over 8,000 new infections in a single day at least once within the past week. With the U.S. Centers for Disease Control and Prevention (CDC) estimating that we may only be detecting 10% of all infections, these cases are only the tip of the iceberg.
While cases are plateauing and even trending downward in some areas, this level of circulating virus will not be reduced quickly enough for schools, businesses, and other key institutions to safely open. Once colder weather sets in, people will spend more time indoors, and the flu and other seasonal respiratory illnesses — which cause symptoms similar to Covid-19 — will also begin circulating and further strain already-insufficient testing capacity. In addition, more and more evidence show that Covid-19 may cause serious and lasting health effects — even in younger people who have only mild infection.
New Approaches to Lockdowns
Consequently, a new round of lockdowns should be implemented to prevent the current worrisome situation from becoming much worse. But we believe that they should be applied in a way that is tailored to local conditions.
Targeted lockdowns. While some are calling for repeat nationwide lockdowns, some counties remain with little transmission. Rather than a blunt approach that unnecessarily affects areas with fewer cases, we should disaggregate epidemiological data down to the level of individual cities and towns and only lock down in areas where they are absolutely necessary. Places where hospitals bed, staff, and ICU capacities are already strained are well past the point when lockdowns should have been implemented and need to impose them immediately.
In other places, absolute levels and trends in test positivity rates, testing capacity and turnaround times, and new cases per capita should be used by state and local health officials to decide if lockdowns are needed. (The specific cutoffs are an area of some debate. Many states have test positivity rates and new daily case numbers well beyond any of the varying cutoffs different experts have proposed.)
Focus on high-risk scenarios. While initial lockdowns were blanketed across most commercial and public venues, smarter lockdowns should mainly focus on restricting venues or scenarios we’ve learned most often lead to transmission and superspreading events (e.g., bars, gyms, concerts, indoor dining, and crowded public transport). Many of these venues continue to remain open even in areas with rising cases. Local information on where infections are occurring can be used to identify other specific venues and to tailor the response according to most likely locations of spread. (This is bound to vary by community, county, state, and region.)
Only absolutely essential services such as gas stations, grocery stores, and pharmacies should remain open. Stores selling non-essential goods and restaurants should only be open for outdoor service and curbside pick-up. With evidence showing that outdoor transmission is far less likely, outdoor areas such as parks and beaches should remain open, and outdoor alternatives should be created for many of the activities we do indoors, such as drive-in movies and outdoor workout classes, especially as we are still in the summer and fall months. This will be harder to do in the winter and is all the more reason to act quickly now.
Protect essential workers. The absolutely necessary businesses that remain open must implement practices that can minimize transmission. These include staggering shifts and providing workers with proper personal protective equipment, including masks with better filtration than cloth masks offer. Moreover, workplaces should make efforts to restructure ventilation systems to provide better filtration and exchange capacity as an additive measure, and we should study the effects of these changes in trials that can help us understand their role in reducing transmission.
Many experts, including us, have advocated these types of measures for months, but they continue to be applied inconsistently. For nonessential sectors where people cannot work from home, the federal government should provide workers wage subsidies similar to what many other high-income countries have done during the pandemic.
Prevent lapses in health care unrelated to Covid-19. To avoid a spike in deaths from non-Covid-19 health issues as early data suggests happened during the initial lockdown, health systems should proactively advise communities that it is safe and necessary to come in for emergencies. Many already have “advice” lines that patients can call and speak with a nurse who can guide them on how quickly they need to be seen.
These services should be bolstered to ensure people do not delay seeking necessary care. In addition, primary care offices — many of which are facing a financial crunch from the decline in patient visits — should reach out to their highest-risk patients to check on them and, as many already are doing, provide telemedicine-based appointments.
Institute a Nationwide Public Health Response
These approaches can make new lockdowns more palatable, but, ultimately, no matter how thoughtfully executed, lockdowns are not a strategy. Rather, they are an emergency stopgap to not only “flatten the curve” and prevent health systems from being overwhelmed but also to allow for a true public health response to be set up. This is what we woefully failed to do in much of the country the first time around. It needs to be done now to end the cycle of uncontrolled spread.
We need to establish an effective epidemic response with adequate testing, contact tracing, and isolation and ensure widespread availability and use of better masks. We need to consider bolder strategies to disrupt transmission such as universal daily screening with rapid paper-strip tests. We need epidemiological systems at the local level that can account for how and where cases are happening so that information can guide where further efforts are needed.
We need to forge strategies through an equity lens that can allow us to see how many recommendations, such as asking people to shelter in place and work from home, are impossible to do for many people in the hardest-hit communities who have no choice but to keep working. We need to also make sure that this time, reopening is driven by the same key epidemiological and clinical metrics used to determine if lockdowns are needed, the establishment of adequate response capacity, and the wisdom of public health expertise, not political pressure.
Lastly, we must ensure that there is public buy-in, given the fatigue that many are struggling with and the immediate hesitancy that the word “lockdown” can bring. We must ensure that people understand that smarter lockdowns are very different, and far more palatable, than what had to be done in March and April.
Renewed, smarter, targeted lockdowns can bring the surging tide of infections back down to controllable levels while we institute these systems that can give us a fighting chance of finally bringing Covid-19 under control throughout the United States.
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August 12, 2020 at 07:26PM
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