When to reopen America?

By , Guest Columnist Updated: March 26, 2020 7:11 PM CT | Published: March 26, 2020 3:52 PM CT
Manoj Jain
Guest Columnist

Manoj Jain

Dr. Manoj Jain is an infectious disease consultant at Baptist Memorial Hospital and Methodist Hospitals in Memphis. He is also a clinical associate professor at the University of Tennessee-Memphis and the Rollins School of Public Health at Emory University in Atlanta.

Kenneth G. Castro
Guest Columnist

Kenneth G. Castro

Dr. Kenneth G Castro is on the faculty at Rollins School of Public Health, Emory University.

Carlos Del Rio
Guest Columnist

Carlos Del Rio

Dr. Carlos Del Rio is on the faculty at Rollins School of Public Health, Emory University. 

The question vexing economists, politicians and everyday Americans is when can our country re-open.

It’s hard to be socially distanced at home when everything seems normal outside in the streets. However, this is not the view of health care workers in facilities and hospitals who are overwhelmed with having to evaluate large numbers of people with signs and symptoms of COVID-19 and need the appropriate facilities for treatment of severe respiratory illness.

Health dept. head: COVID-19 testing ‘sufficient,’ with full numbers in a week

The president (based on his wish and not science) proposed Easter Sunday, April 12, as the day when we can go to churches and business can begin as usual.

Medical experts cringed. Yet the COVID-19 epidemic has had many twists and turns and the president has been right in restricting travelers from China and other highly affected countries.

But on other occasions, the president has been devastatingly wrong, as when he called coronavirus a “hoax” against the advice of medical experts.

We are suffering the consequences of a delayed national response in the deployment of test kits and relatively limited access to basic protection equipment for health providers.

So how do we balance these tensions?

As infectious disease doctors and epidemiologists treating COVID-19 patients in the hospital and advising mayors of several cities, we see the need to delve deeper into what is being learned about this novel disease science and find nuanced solutions. 

A simple graphic based on the University of Pennsylvania estimator shows how the epidemic will evolve based on U.S. COVID-19 data from March 25, 2020.

We see 54,941 cases with 2.13% critically ill COVID-19 patients. Extrapolating from this, a conservative estimate for the United States would be that 5% of these patients are hospitalized and 2% require intensive care unit (ICU) services.

With no proven treatment regimen and no vaccine at hand, public health experts have to rely on non-pharmaceutical interventions, such as social distancing. Implementing lockdown in this graph assumes social distance greater than 65%, while partial opening is 45%, and mostly open given present circumstance of caution may result in 25% social distancing in the formula calculation.

Based on estimated numbers of cases today in the U.S., we calculate the hospital census peak at 1.25 million, 500,000, or none based on low, mid- and, high level implementation of social distancing.

Yet bed capacity in the U.S. is limited to 924,000, which would imply that ceasing social distancing at once risks would create a scenario similar to what has been observed in Italy, requiring rationing of health care and leaving doctors to face the ethical conundrum of having to choose who lives or dies, who gets a ventilator and who does not. The situation for ICU beds would be more dire.

So what can we do?

We propose a two-part solution. First, we can work on gradual re-opening with a focus on strategies that facilitate social distancing without having us confined to our homes or being 6 feet apart at all times.

Second, this measure must be coupled with rapid testing (with same-day results) for SARS-CoV-2 and comprehensive contact investigations to identify who needs to be targeted for social isolation to limit the spread of the virus. By implementing this staged approach, we can sustain a path to nearly 45% to 65% social distancing and flatten the curve. 

Health departments, if bolstered with additional personnel, can “whack the mole” each time a case crops up. Once the number of cases decline in a community we can begin to ease the restrictions. With success, such a strategy is used by state and county Health Department-based tuberculosis programs nationwide and would allow the safety of health care workers and the public, those at highest risk of severe consequence of COVID-19.

A sudden stop to social distancing and stay-home orders is an injustice to all the health care workers who risk their lives to care for COVID-19 patients.

As physicians we opt to remain under lockdown until we have the equipment and a plan to strategically ease restrictions in a step-wise manner. Politicians may instead consider that the best option is to cut and run.

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Dr. Manoj Jain coronavirus Dr. Kenneth G. Castro Dr. Carlos Del Rio


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