Research and Updates on Continued Control and Management of COVID-19 as of July 22

WHO Guidance 

The World Health Organization's (WHO) Director-General has spoken about the easing of physical distancing restrictions. He reminded countries that physical distancing restrictions are only part of the equation, and there are many other basic public health measures that need to be put in place.  He noted that COVID-19 accelerates much more quickly than it slows down, emphasizing that control measures must be lifted slowly and with control. Six factors were listed to consider before lifting restrictions: 

1. Transmission is controlled; 
2. Health system capacities are in place to detect, test, isolate and treat every case and trace every contact;  
3. Outbreak risks are minimized in special settings like health facilities and nursing homes; 
4. Preventive measures are in place in workplaces, schools and other places where it's essential for people to go; 
5. Importation risks can be managed; 
6. Communities are fully educated, engaged and empowered to adjust to the "new norm" 

On April 14, the WHO published a COVID-19 Strategy Update available here. 

On May 12, the WHO published an annex to the interim guidance document, released April 16^th, that provides a decision process to help countries through adapting public health and social measures based on epidemiological and public health criteria. 

On May 18, the WHO published additional interim guidance with the purpose of providing an overview of public health and social measures that can be implemented to slow or stop the spread of COVID-19, and to propose strategies to limit any possible harm resulting from these interventions.  

On April 24, the WHO's Regional Office for Europe published policy considerations to support the European region in managing transitions and modulating physical distancing measures. In the news release, it was emphasized that one size does not fit all as the challenges faced by each country varies, that the easing of measures may have to be staggered over a period of time, and that the process is prone to short-term change. These policy considerations include four key components: 

• Public health and epidemiological measures that drive the decision-making process; 
• Capacity for dual-track health system management to reinstate regular health services, while continuing to address COVID-19; 
• Population and behavioural insights for responsive engagement with populations; and 
• Social and economic support to mitigate the effects of COVID-19. 

On November 4th, 2020, the WHO released updated interim guidance on implementing and adjusting public health and social measures.

• The guidance outlines situational levels based on the intensity of transmission and capacity of the health system to respond. Each level includes considerations for implementing public health measures, such as closing essential businesses, leaving schools and childcare open, and asking individuals to limit contact and gatherings.
• Specific indicators and thresholds for gauging the extent of transmission and capacity to respond are also defined.
• Transmission is based on hospitalization rate, mortality, case incidence (per 100,000 per 7 days), and test positivity. Other indicators such as the effective reproduction number, doubling time, and the proportion of cases with no epidemiological link may also factor into the assessment of community transmission.
• Health system and public health indicators include the proportion of occupied hospital beds, case fatality rate, testing rate (per 1,000 per week), proportion of contact tracing investigations completed in 24 hours of identification, and adherence to public health measures. The number and proportion of filled ICU beds, and the number of contact tracers are also factors that can be considered.

US Centers for Disease Control and Prevention (CDC) Guidance 

• The CDC has released a series of decision tree flow charts for reducing the risk of transmission in specific businesses as they consider reopening. Flow charts are available for: 
• Schools; 
• Restaurants and bars; 
• Youth programs and camps; 
• Child care programs; and 
• Mass transit. 
• The CDC has also released a plan outlining activities and initiatives to support reopening of the US. 
• The plan includes six "gating" criteria and associated indicators that can be used to determine when to move to a subsequent phase of reopening. 
• Emphasis is put on the public health capacity to test, interview new cases, undertake contact tracing and initiate a comprehensive proactive surveillance. 

Snapshot of Early Research on Easing of Physical Distancing Measures 

• Historical data and modeling evidence suggests that strong physical distancing measures temporarily suppress new cases, but also leave a large proportion of the population susceptible to infection, risking a resurgence of cases when restrictions are lifted. 
• The American Enterprise Institute has published a report to provide guidance on easing physical distancing and other shelter-in-place restrictions. 
• Initial "slow the spread" measures (i.e., physical distancing, school closures, closure of non-essential services) are put in place to slow the transmission sufficiently in order to massively scale testing/contact tracing and health system capacity (includes beds, PPE, equipment). During this phase, states are encouraged to also implement a comprehensive surveillance system to identify early community spread. 
• The move to a second phase of more relaxed measures (i.e., schools and businesses are open) but with continued limitations on gatherings and physical distancing for at-risk populations is possible when there is: 
• Sustained reduction in cases for at least 14 days (i.e., one incubation period) 
• Sufficient hospital capacity to treat all patients requiring hospitalization (suggest 5-7 ICU beds per 10,000) 
• Capacity to test all people with COVID-19 symptoms and conduct active monitoring of all confirmed cases.