6 Keys to Opening as Soon and Safely As Possible

We all want to open things back up. We can open sooner and safer if we address these six areas:

1) Confirm cases and deaths from the virus have been decreasing steadily for at least 14 days.

2) Ensure healthcare systems are ready in case there is a resurgence so health workers are not harmed and patients can be supported.

3) Implement the 'Box It In' strategy through strategic testing, prompt isolation, contact tracing, and quarantine to keep the virus in a box.

4) Protect those most vulnerable to the virus – older and medically vulnerable people will need to shelter and shield for longer.

5) Have new safety measures in place – open in phases, waiting at least 3 weeks to see if there’s spread between steps, use hand sanitizer, door-front shop pickups, open spaces, physical distancing, and more. We need creativity to re-design for safety in the Era of Covid.

6) Track the virus closely to implement physical distancing again if virus spread could overwhelm our health or public health services.

A Concept of Operations for the War on Coronavirus

By Dr. Tom Frieden

Along with our Preventing Epidemics team at Resolve to Save Lives, we have developed a concept for the different phases in the response to the COVID-19 pandemic and what needs to be done differently at different times. It’s a war strategy, and like any strategy, will need to be adjusted as we learn more about the virus and about what works to limit spread. The basic concept is below, and I’ve written in more detail about it here.

This figure outlines response measures in COVID-19 containment and mitigation. Disease control activities to reduce spread and effectively treat those infected should be in place from the start of an outbreak. Contact tracing is critical in containment but is not used in areas with extensive spread in communities. Routine non-pharmaceutical interventions (NPIs) are also used early on as they are in a typical flu season, and include washing hands, covering coughs, staying home when ill, and making sure surfaces are cleaned. If COVID-19 spreads widely, additional NPIs may be implemented, including additional personal measures such as staying home if a family member is sick and community measures such as mandatory telework and canceling mass gatherings. These measures will dampen the impact of the pandemic in the hope that pharmaceutical interventions such as antiviral treatments and vaccines become available.

COVID-19 articles from Dr. Tom Frieden over the past 2 months - all in one place, along with some podcasts

January 22

Jan 22: article in STAT: 3 key questions about novel coronavirus in Wuhan China

On January 22, Dr. Frieden wrote about the need to learn more about the pathogen, a summary of some of the first scientific articles, the need for more investment in global preparedness, broader reflections on politics and epidemics, and analysis of the implications of extensive spread in one hospital in Wuhan. At the request of China CDC, he outlined 5 components that contribute to the US CDC’s effectiveness keeping the U.S. and world safer. He also published this analysis of reasons for both optimism and pessimism, as well as some next steps in either case.

February 25

By February 25, it was clear that the virus would become a pandemic, and he outlined the next steps we need to take to reduce the health, social, and economic harms it will cause.

February 28

On February 28, along with colleagues from Resolve to Save Lives, he analyzed how to assess the severity of the pandemic and how to save the most lives and they repeated this analysis stratified by age group with updated information on March 10.

March 2

On March 2, Dr. Frieden called onCongress to protect the United States by including funding for global health protection in the supplemental appropriation. He outlined 19 critical data gaps we need to fill to respond effectively to COVID-19.

March 8

CNN Health: It’s time to restrict visits to nursing homes

By March 8, it was clear that COVID-19 would hit the US hard and Dr. Frieden called for restricting visits to nursing homes and a series of other measures to be taken by everyone, medically vulnerable people, health care systems, and the government. As the pandemic hit the US, he urged 10 steps to prevent what could be a large disaster taking as many as 1 million lives. Dr. Frieden also reflected on the most important lessons from the Ebola epidemic to address the COVID-19 pandemic. Dr. Frieden clarified the differences between flu and COVID-19, and noted that although too many people will die from this, it, too, will pass.

March 16

As the pandemic spread in the U.S., on March 16, he wrote of 7 potentially deadly errors in the response. Dr. Frieden outlined some the most important questions about the virus and how we might answer them. As a New Yorker, when COVID-19 began to spread widely in our city, he urged residents to protect themselves and others and looked forward to some positive results the tragic pandemic might bring. Drs. Shahpar and Frieden summarized the reasons for concern about the possibility that the need for intensive care could far outstrip supply in the United States.

Facing the acceleration phase of the pandemic in New York City and learning from experiences around the world, Dr. Frieden suggested a war strategy to confront the virus, updating the strategy published one month earlier. Stopping smoking, getting physical activity, controlling diabetes all build our resistance, and so may getting enough Vitamin D, and, more broadly, how we need to better prevent and control heart disease to increase individual and community resilience. Alarmed by haphazard and misinformed approaches to resuming social activity, he outlined a strategy to restart activities as soon and safely as possible, turning the faucet slowly rather than opening the floodgates.

March 18

Joined by colleague Dr. Christopher Lee, he reviewed the scientific data on superspreading events and the implications for control of COVID-19.

March 27

Alarmed by the continued large numbers of patients seeking care for mild illness, he urged New Yorkers with symptoms to stay home unless they have trouble breathing. Based on work fighting epidemics in the U.S. and globally, he recommended ways to improve management of the U.S. response.

March 30

Recalling Surgeon General Koop’s letter to every household in the United States in 1988, he drafted a letter that could be sent – along with a digital thermometer – to every household today.

March 31

He wrote to clear the air on coronavirus testing and outline a way forward that puts testing in the context of comprehensive pandemic control, and joined his long-time colleague Dr. Sam Dooley in providing practical tips for the public to stay safer.

April 1-6

Following a media briefing and press statement on the topic, Dr. Frieden outlined the way forward to reopen society as soon and safely as possible without risking explosive spread of the virus.

He summarized simple steps everyone can take to reduce risk.

April 9

He joined Dr. Sam Dooley in answering common questions about mail, packages, and groceries for those who are worried about doing this in the time of COVID-19. One month after outlining 19 questions about COVID-19, Drs. Frieden and Shahpar provided a detailed review of the astonishing progress answering most of these questions – and the crucial 6 questions that still need to be answered.

April 11

I spoke with Fox News about #BoxItIn and in my Op-Ed for today’s New York Times I outlined why and how the administration needs to let CDC guide the work to reopen our communities and economy as soon and safely as possible.

Podcasts and interviews

Podcast with Senator Bill Frist, MD

Council on Foreign Relations podcast Why It Matters

Council on Foreign Relations 1 hour session for business

Podcast with Dr. Kelly Henning of Bloomberg Philanthropies

Firing line with Margaret Hoover of PBS

Dr. Tom Frieden on 19 Critical Data Gaps Limiting our Effectiveness Responding to the COVID-19 Pandemic

The more we know, the better we can protect people against COVID-19. Here’s a set of the most important questions to be answered. Although we learn more about this virus every day and have some information on some of these questions, much of that data is preliminary, imprecise, or potentially inaccurate. Furthermore, answers may differ among areas and over time in the context of COVID-19. And of course, there are other important questions, including those that will be generated by the emerging answers to these questions. 

Transmissibility

1.     How is the virus spreading? 

2.    How contagious is the virus (the Ro, or basic reproductive rate)?

3.    How common is spread from contaminated surfaces? 

4.    How effective is increasing ventilation at reducing risk? 

5.    How much spread is from asymptomatic cases? 

Testing

6.    How sensitive are PCR assays – what is the false-negative rate from properly collected nasopharyngeal samples?

7.     Is serology accurate, and what is the time course of antibody response?

8.    Can an accurate, rapid point-of-care test be developed?

Severity

9.    How deadly is the virus? Reported case fatality rates are likely to greatly over-estimate death rates because there are so many undiagnosed cases. 

10. Which are the most vulnerable groups we need to protect – which underlying diseases increase risk the most?

11.  Do different types of virus cause different levels of severity? 

12.  Is the virus changing genetically in important ways as it spreads?

Treatment

13.  What treatments work to decrease the severity of COVID-19 disease? If there are effective anti-viral treatments, not only can patients’ lives be saved, but the duration of intensive care stay can be reduced. This would allow more patients to be treated and reduce the risk to health care workers, and contacts could potentially receive preventive treatment to reduce spread.

14.  Can a preventive medication be identified to be given to contacts of patients with COVID-19 as is done for influenza with oseltamivir (Tamiflu) in nursing homes and other areas?

15.  Is there any role for steroid treatment of patients with severe pneumonia caused by SARS-CoV-2?

Control

16.  What works to change behavior, including hand-washing and cough hygiene? Telling people what to do gives leaders a sense they are doing something, but does it actually work? We can only know and improve our messaging by objectively monitoring how people respond.

17.  What works to limit spread? For example, will school closures make a difference? Since children don’t appear to get ill even if infected (unlike with influenza), they may not be important as sources of infection – and school closures may (or may not) have limited value. We will only know as we learn more and rigorously evaluate our attempts to do more to control spread.

18. What are the most important ways to protect health care workers and patients in health facilities? If cases increase rapidly, it will be crucial to be able to continue to provide care, and do so without risk to health care providers or other patients.

19.  How can creation of a safe and effective vaccine be accelerated?

Good data is the lifeblood of good public health. The sooner we get answers to these questions, the sooner and more completely we can do what’s needed to reduce infections, improve survival, and reduce societal harms.

Dr. Tom Frieden is former director of the US Centers for Disease Control and Prevention and former commissioner of the New York City Health Department. He is currently president and CEO of Resolve to Save Lives, a global non-profit initiative funded by Bloomberg Philanthropies, the Chan Zuckerberg Initiative, and the Bill and Melinda Gates Foundation and part of the global non-profit Vital Strategies. Resolve to Save Lives works with countries to prevent 100 million deaths and to make the world safer from epidemics. Dr. Frieden is also Senior Fellow for Global Health at the Council on Foreign Relations.@DrTomFrieden.

What saved 20 million lives in the US and could save 100 million globally?

By Dr. Tom Frieden

At its peak in the 1960s, heart disease killed 1 in 100 people over age 35 in the United States every year. Then death rates began to drop, and, remarkably, continued to do so until 2010. This decrease—the result of both public health interventions and improved medical care—saved more than 20 million lives and accounted for three-quarters of the increase in life expectancy in the United States. In recent years, progress has stalled. There is much more that can be done to prevent heart attack and stroke. In the United States and around the world, governments can tax tobacco, alcohol, and sugary drinks, improve the availability of healthy food, and incentivize primary health care systems to improve blood pressure control and cholesterol treatment. Health systems and medical providers can prioritize blood pressure control, which can save more lives than any other adult health care intervention. Individuals can feel better and live longer by getting more physical activity (walk for transit and fun), eating healthier food with less sodium, avoiding tobacco and second-hand smoke, and taking medications for as long as needed.

Tom Frieden, M.D., is president and CEO of Resolve to Save Lives, a global nonprofit initiative housed at Vital Strategies that works with countries to prevent 100 million deaths and make the world safer from epidemics. He is the former director of the Centers for Disease Control and Prevention and former commissioner of the New York City Health Department.

Dr. Tom Frieden, Former CDC Director, on the Latest Scientific Developments, and Implications for Novel Coronavirus Prevention and Control

At the end of a busy week of our usual work at Resolve to Save Lives in epidemic prevention and cardiovascular health, combined with requests to advise on and discuss the rapidly evolving coronavirus outbreak, I sat down to read seven scientific articles about coronavirus that had come out in the past day. These give us more information than we’ve ever had, but leave many key questions unanswered. Our understanding of nCov2019 is rapidly evolving – with new information nearly every hour. These findings can be revised or reversed - early in an outbreak, there's a "fog of war" reality. The first case in the epi-curve that was just published (see Figure) was from December 1, and there was no uptick in cases until around December 20, with the first alert reported on December 31 – a relatively rapid reporting interval.

Here’s a quick summary of the key findings from the scientific publications:

• It’s now highly likely that, as suspected, the ancestral source is bats and the first location may have been the wet market in Wuhan – detailed genetic analysis as well as the largest epidemiological investigation published to date show that 27 of 41 initial cases had exposure to the market. As noted, this virus and bat coronaviruses are close relatives. (Why are bats the cause of so many bad pathogens for people? They are mammals and live in huge cities... sound familiar?)

• This coronavirus behaves somewhat like SARS, which it resembles genetically, but is much less deadly, and possibly more infectious. In particular, it seems to attack the lower respiratory tract, because of receptor binding to ACE2, which is found predominantly in the lung. Symptoms are mostly related to the lung, and x-rays show viral pneumonia. The virus, which is an RNA virus prone to replication errors, may well mutate and evolve in the coming months and years.

• Superspreader events – one individual or event resulting in many infections – are likely to occur or to have occurred, as they did with both SARS and MERS.

• Nosocomial transmission (spread within health care facilities), which was a major source of spread for MERS and SARS, has occurred and remains a major risk for nCov2019 – and is also a major intervention point for control. (The link above is to a familial cluster which may have started with nosocomial transmission. Although this is not proven, it’s clear that nosocomial transmission is occurring.)

• From a meticulous description of a family outbreak, it appears that the incubation period may be 3-6 days, at least for some patients, and it is proven that the disease can spread within a household.

• One of the leading global units that models disease outbreaks estimates that the reproductive rate, Ro, has been 2.6 (estimated range 1.5-3.5) so far. This is a high number that is consistent with rapid spread observed. The authors note that Ro can decrease as control measures are implemented, but note: “Whether the reduction in transmission is sufficient to reduce R to below 1 – and thus end the outbreak – remains to be seen.”

• At least one hospital in Wuhan has begun a clinical trial of antiviral agents.

In addition, public reports indicate increasing recognition of cases in many areas of China, and cases are being identified in an increasing number of countries on several continents. It’s possible that nCov2019 will spread more readily than SARS did, although we don’t know that yet.

What does that all mean?

• We still don’t know how infectious the disease is and will remain, but it certainly has been infectious.

• We still don’t know the denominator – how many people are infected, what proportion don’t have symptoms (although some are without symptoms, including a 10-year-old child), what proportion have mild illness – so we still don’t know the case fatality rate. However, at this point it appears likely that the mortality rate is lower than it was for SARS (11% for SARS vs. 3-4% so far for nCov2019 – 25 deaths out of 835 diagnosed patients initially, although some of those 835 may die, and the total number infected is undoubtedly much higher than 835, hence the actual mortality rate is likely to be lower, and perhaps far lower).

What should be done?

• For most people in the US, nothing different. Wash your hands regularly. Cover your mouth and nose when you cough or sneeze. Don’t go to Wuhan, and consider other travel to China carefully – discuss with your doctor. (For staff in China – work from home to the greatest extent possible, avoid crowds and, if possible, avoid health care facilities unless you’re sick.)

• Meticulous infection control in hospitals in China and other areas with infected patients, including rapid detection and isolation of patients with cough, respiratory protection, gloves, disinfection, and the other strategies that controlled SARS and MERS in hospitals. This will protect health workers and decrease the amplification of spread of the virus.

• Get more epidemiologic information. How many episodes of nosocomial transmission have there been? What has been studied for each? There’s a big difference if the virus has been spreading from high-risk, aerosol-generating procedures such as sputum induction and bronchoscopy, as opposed to spread in waiting rooms and through other casual contact. Have there been superspreader events? For each recognized outbreak with transmission links, what are the most likely modes of spread and what control measures have been tried, with what effect?

• Intensive laboratory work, including testing symptomatic patients (and, in some special studies, contacts), developing serological tests, and collecting multiple virus specimens to monitor for genetic changes.

• Establish additional sentinel sites in China to determine what proportion of people both with and without symptoms who attend health care facilities are infected.

• Each country should review its ability to find, stop, and prevent coronavirus cases

• In the medium term, decide whether live markets should be regulated far more strictly, or closed completely. This won’t change the current outbreak, but allowing the current arrangement to continue, which leads to outbreaks, is not a responsible option.

Dr. Tom Frieden (www.DrTomFrieden.net) is former director of the US Centers for Disease Control and Prevention, and former commissioner of the New York City Health Department. He is currently president and CEO of Resolve to Save Lives, a global non-profit initiative of Vital Strategies, working with countries to prevent 100 million deaths and make the world safer from epidemics. Twitter @DrTomFrieden.

Links to articles cited and linked above:

A Novel Coronavirus from Patients with Pneumonia in China, 2019, New England Journal of Medicine

Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China, The Lancet 

Another decade, another coronavirus, New England Journal of Medicine

Coronavirus infections, more than just the common cold, JAMA

A Novel Coronavirus Emerging in China – Key Questions for Impact Assessment, New England Journal of Medicine

A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster, The Lancet

Transmissibility of 2019-nCoV, Imperial College.