Note: This a long read. If you aren't in the mood and would prefer to clean out the gutters for the third time this month, please join us Tuesday morning at 10 am and we will cover the current data, policy and what the governors are up to. Add to your Outlook Calendar.
On Thursday evening the White House released a plan to replace existing CDC guidance on physical distancing and hygiene measures currently in effect in most states in the US. The plan relies on standard public health procedures of surveillance, testing, contact tracing and physical distancing, while avoiding some of the weaker science and technology fads that have been swirling in media reports. Governors are not required to adopt the recommendations as they control public health responses within their own borders, the president's recent statements notwithstanding. However, every incentive of the governors, the president, business interests and the general public is aligned to more or less follow the course laid out on Thursday.
What is in the Plan?
The plan calls for, first, gating criteria states should satisfy before proceeding to the three phases for relaxing standards. These gating criteria rely on existing syndromic surveillance systems for Influenza-like Illness augmented by a new one for COVID-19-like Illness. Other gating criteria include reports of confirmed COVID-19 cases and test results. Finally, the all important health care delivery capacity will need to be sufficient and properly protected.
What the plan does not require, to the derision of some, is widespread, random diagnostic testing of the population similar to the approach in South Korea and Singapore. (I will leave my rant on testing for another day.)
Syndromic Surveillance. Like many countries, the US has an influenza surveillance system. Our system relies on what are known as "sentinel" providers who report throughout the flu season ER/outpatient visits and inpatient admissions for confirmed influenza cases. Importantly, the US also requires sentinel providers to report diseases that present in a manner similar to influenza but for which there is not a confirmed diagnosis. Cases known as ILI, or Influenza-like Illness, are typically characterized by the very things associated with COVID-19; fever, cough, and/or shortness of breath.
These data are reported by the 700 or so sentinel providers to state health departments and to the CDC. Generally, the most recent report is a couple weeks old.
Additionally, New York City, which pioneered syndromic surveillance in the years after 9/11 and the anthrax scare, requires reporting from all its hospitals and makes that data public on a two day lag. We highlighted ILI data back in mid-March as a predictor of sorts for the New York area.
The administration is expanding the Syndromic Surveillance system to accomodate COVID-19-like data. COVIDView, a weekly report on COVID-19 cases has been rolled out at the CDC and includes, at the national level, cases of COVID-like illness. We assume that the CDC is developing a dashboard for COVID-like similar to the ILI data set found here.
The White House is recommending that states have a 14-day downward trajectory of ILI and COVID-like reported data as one criteria before considering moving on to Phase I of relaxed standards.
Cases. The second element of a the gating criteria is a recommendation that a state have a 14-day downward trajectory in COVID-19 cases OR a downward trajectory of positive test results, assuming flat to increasing test volumes.
For the next six weeks or so, we would expect states to rely more heavily on confirmed cases as testing remains a challenge. There are states with robust testing programs in place like New York but most remain frustrated by supply chain problems, less than cooperative laboratory directors, labor supply and availability of high through-put testing platforms. The good news is that confirmed COVID-19 case data combined with ILI and COVID-like syndromic data ought to provide sufficient surveillance in the near term.
Testing is expected to ramp throughout May and June under state-sponsored programs. Additionally, employers are already putting in place routine testing programs for employees. FDX has had a program in place since January. AMZN announced one last week. As COVID-19 is a reportable disease - meaning a positive test will be reported to the state health department and to the CDC, this employer-based system will significantly augment the state and health system based capabilities currently in use. The problem of accuracy will remain but let's save that for my later testing rant.
The CDC has not yet launched a timely dashboard for state or county level reporting as they have for the flu. However, over the last several weeks, states have ramped their reporting to the public. We will continue to collect caseload and testing data at the county level so as to accurately predict which states have cleared these gates. If you wish to get a copy, please email
Health Care Capabilities. The third gating element presents much less of a challenge for states. As far as we can tell, during the present surge, only New York City Metro and Albany, GA hospitals resorted to crisis care. For the non-health care reader, crisis care is a level of operation designed to maximize critical resources like ventilators, PPE and labor. The ability of the US health care system to navigate the current surge is a result of spending 20% of GDP. The system is massive and flexible. As much as we like to bemoan that from a fiscal perspective, it saved our bacon and will likely continue to do so until COVID-19 is resolved one way or another.
Additionally, the gating criteria recommend a robust testing program for health care workers, including use of regular antibody testing. The challenges for testing apply here but health care workers have been a priority for large reference and health system labs and that will continue to be the case. Antibody testing is expected to be widely available by the end of May. Unlike a diagnostic test, antibody testing is low-tech and, for the most part, can be conducted at hospital labs.
Clearing the Gate and Moving On to Phased Relaxation
States that satisfy the gating criteria - assuming a governor accepts the White House's recommendation as we believe they will - should move on to a phased relaxation of social distance standards.
According to our analysis of ILI data (COVID-like not being uniformly available) and COVID-19 caseloads there are 11 states that should qualify. Given the daily variability of reported confirmed cases, we are determining declining caseloads by taking the average case per 100,000 people for consecutive 14-day periods and comparing the most recent periods.
Of these 11 states, there are some mitigating factors that may delay implemenation of a Phase I. For example, Colorado, Louisiana and Michigan have declining caseloads but very high (25%,26% and 46%, respectively) positive test rates. Although the criteria make declining positive test rates an alternative to declining case rate, their governors are likely to wait until more tests can be performed and the positive rate is reduced. Oregon has joined a state compact with Washington and California - states much more impacted - and so may restore activity later than necessary as they coordinate the effort with the two other governors.
All of these states have experienced declining ILI cases.
There are an addiitonal 11 states that have experienced a single 14-day period of declining cases.
Vermont has already announced the re-opening of non-essential businesses for home delivery and curb-side service. California, due to the difficult situation is Los Angeles masking otherwise improvement in the rest of the state, and Washington are likely to go slow as part of their regional cooperation.
Not meeting the White House's criteria are two states that will nontheless start moving toward new relaxed standards. Texas and Tennessee have indicated an interest in moving quickly. They are both dependent on sales tax reciepts for state and local budgets and, to be fair, COVID-19 is highly concentrated in a few of the Metro areas.
What Isn't In The Plan.
Technology-dependent solutions. Before Thursday, there had been lots of reports circulating about technology-based solutions similar to those used in Asia. GOOG and AAPL have teamed up to create an app that facilitates contact tracing. The idea has many flaws - it requires widespread adoption to be useful and uses Bluetooth to identify contacts. Unfortunately, widespread adoption is not probable without some constitutionally questionable mandate. Bluetooth technology has a range of about 33 feet and would capture as contacts many people not likely to be affected and in numbers that would quickly overwhelm a local health department's capacity. It's a nice gesture and maybe some iteration someday will be helpful.
Immunity Certificates. Another idea that seemed to get a little traction - if you can call a few press reports "traction" - is a requirement that those who test positive for the COVID-19 antibody carry around proof in exchange for certain freedoms. A proposal of this nature would last as long as it took the ACLU to change the date on the complaint and get to the courthouse. The bigger problem is that the research has not yet been conducted on immunity from COVID-19. Questions like whether the presence of an antibody confers immunity and how long that immunity lasts are yet to be answered. Regular testing of health care workers will go a long way in gathering the necessary data to be studied.
Mandatory Face Masks. The White House plan suggests use of face coverings when in public, especially when using mass transit and avoids any mandatory standards. The question of face masks has been hotly debated at the White House. The science is best described as "it can't hurt." The policy and political implications are more daunting. A policy concern is that PPE remains, and will remain for many months, in short supply. Any suggestion of its use outside of critical infrastructure industies will only exacerbate the shortages. Another policy concern is that face masks may give the wearer a more relaxed attitude toward other, more established public health responses like physicial distancing. The politcal reality is that a mandatory face mask order may be percieved by the president's base as caving to the press, who made it a significant line of inquiry for several weeks, even in the absence of scientific consensus.
Will It Work?
It should. The plan relies on a tried and true influenza surveillance system that has been in place in states for years. The COVID-19 caseload data continues to improve with the testing challenges acknowledged. Health care capacity and expertise are now well documented. The phased in approach with a 14-day waiting period between each phase means a resurgence of disease can be detected before going on the Phase II or III.
The biggest challenges are the supply chain and other issues associated with testing and proper staffing of local health departments for tracking contacts. Communities in Washington, Oregon and Nebraska have demonstrated what is possible. Massachusetts has committed to hiring 1,000 public health workers. Other efforts will be rolled out in the coming weeks. There is no time to waste but meeting the demands of COVID-19 is well within the capabilities of the US public health system.
Now, optimism for an adequate public health response is not the same as being bullish on the US or global economies. In Phase I, large venues like casinos, arenas, stadiums, convention centers and hotel meeting rooms will have their occupant loads lowered by half or more. Same goes for restaurants and gyms. (For you modelers, a maximim occupant load for a large venue like a convention center is about one person per seven square feet.) Elective surgeries will have to be performed in ASCs or hospital outpatient departments, significantly reducing the number of procedures. In Phase II and III, occupant loads can be increased but the plan does not envision any circumstance under which places where people gather; bars, restaurants, concert arenas, stadiums, gymnasiums, will be functioning at 100% capacity unless and until the medicine improves or a vaccine is developed.
We will adapt to all these changes, of course. It is an inevitability of the American economy and its people. But it will take time. Less than we think but more than we want.
Let me know if you have any questions.
Emily Evans
Managing Director – Health Policy
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