Public health mitigation of COVID-19

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Goals of mitigation include delaying and reducing peak burden on healthcare (flattening the curve) and lessening overall cases and health impact. Moreover, progressively greater increases in healthcare capacity (raising the line) such as by increasing bed count, personnel, and equipment, help to meet increased demand. 20200410 Flatten the curve, raise the line - pandemic (English).gif
Goals of mitigation include delaying and reducing peak burden on healthcare ( flattening the curve ) and lessening overall cases and health impact. Moreover, progressively greater increases in healthcare capacity ( raising the line ) such as by increasing bed count, personnel, and equipment, help to meet increased demand.
Mitigation attempts that are inadequate in strictness or duration--such as premature relaxation of distancing rules or stay-at-home orders--can allow a resurgence after the initial surge and mitigation. 20200409 Pandemic resurgence - effect of inadequate mitigation.gif
Mitigation attempts that are inadequate in strictness or duration—such as premature relaxation of distancing rules or stay-at-home orders—can allow a resurgence after the initial surge and mitigation.

Part of managing an infectious disease outbreak is trying to delay and decrease the epidemic peak, known as flattening the epidemic curve. [1] This decreases the risk of health services being overwhelmed and provides more time for vaccines and treatments to be developed. [1] Non-pharmaceutical interventions that may manage the outbreak include personal preventive measures such as hand hygiene, wearing face masks, and self-quarantine; community measures aimed at physical distancing such as closing schools and cancelling mass gathering events; community engagement to encourage acceptance and participation in such interventions; as well as environmental measures such surface cleaning. [5] It has also been suggested that improving ventilation and managing exposure duration can reduce transmission. [6] [7]

Contents

During early outbreaks, speed and scale were considered key to mitigation of COVID-19, due to the fat-tailed nature of pandemic risk and the exponential growth of COVID-19 infections. [8] For mitigation to be effective, (a) chains of transmission must be broken as quickly as possible through screening and containment, (b) health care must be available to provide for the needs of those infected, and (c) contingencies must be in place to allow for effective rollout of (a) and (b).[ citation needed ]

By May 2023, in most countries restrictions had been lifted and everyday life had returned to how it was before the pandemic due to improvement in the pandemic's situation. [9] [10]

Initial containment measures

More drastic actions aimed at containing the outbreak were taken in China once the severity of the outbreak became apparent, such as quarantining entire cities or imposing strict travel bans. [11] Other countries also adopted a variety of measures aimed at limiting the spread of the virus, including resorting to states of emergency. [12] South Korea introduced the mass screening and localised quarantines and issued alerts on the movements of infected individuals. Singapore provided financial support for those infected who quarantined themselves and imposed large fines for those who failed to do so. Taiwan increased face mask production and penalised hoarding of medical supplies. [13] The zero-COVID approach aims to prevent viral transmission, using a number of different measures, including vaccination and non-pharmaceutical interventions such as contact-tracing and quarantine. Different combinations of measures are used during the initial containment phase, when the virus is first eliminated from a region, and the sustained containment phase, when the goal is to prevent reestablishment of viral transmission within the community. [14] Experts differentiate between zero-COVID, which is an elimination strategy, and mitigation strategies that attempt to lessen the effects of the virus on society, but which still tolerate some level of transmission within the community. [15] [16] These initial strategies can be pursued sequentially or simultaneously during the acquired immunity phase through natural and vaccine-induced immunity. [17]

Costs and challenges

Simulations for Great Britain and the United States show that mitigation (slowing but not stopping epidemic spread) and suppression (reversing epidemic growth) have major challenges. Optimal mitigation policies might reduce peak healthcare demand by two-thirds and deaths by half, but still result in hundreds of thousands of deaths and overwhelmed health systems. Suppression can be preferred but needs to be maintained for as long as the virus is circulating in the human population (or until a vaccine becomes available), as transmission otherwise quickly rebounds when measures are relaxed. Until now, the evidence for public health (nonpharmaceutical) interventions such as social distancing, school closure, and case isolation comes mainly from epidemiological compartmental models and, in particular, agent-based models (ABMs). [18] Such models have been criticized for being based on simplifying and unrealistic assumptions. [19] [20] Still, they can be useful in informing decisions regarding mitigation and suppression measures in cases when ABMs are accurately calibrated. [21] An Argentinian modelling study asserted that complete lockdowns and healthcare system overextension could be avoided if 45 percent of asymptomatic patients were detected and isolated. [22] Long-term intervention to suppress the pandemic has considerable social and economic costs. [23]

Efficacy

In August 2020, a working paper by the National Bureau of Economic Research (NBER) questioned major effects of many mitigation and suppression measures. The authors compared the development of casualties connected to SARS-CoV-2 until July 2020, in 25 US states and 23 countries that had counted more than 1.000 overall deaths each. From the date a state passed a threshold of 25 deaths, the statistical study observed a largely uniform development, independently from type and time frame of governmental interactions. Thus, the growth rate of casualties dropped to zero within 20–30 days, and the variability between regions was low, except at the beginning of the epidemics. The authors computed the effective reproduction number Reff with the aid of different models like the SIR model, and found it hovering around one everywhere after the first 30 days of the epidemic. Hence, they did not find evidence for an influence of lockdowns, travel restrictions or quarantines on virus transmission. [24] For contradicting studies, they assume an omitted variable bias. Candidates for ignored effects could be voluntary social distancing, the structure of social interaction networks (some people contact more networks faster than others), and a natural tendency of an epidemics to spread quickly at first and slow down, which has been observed in former Influenza pandemics, but not yet completely understood. The reviewer Stephen C. Miller concludes “that human interaction does not conform to simple epidemiological models”. [25] [24]

Many reviews find high efficacy of mitigation measures such as vaccines, face masks and social distancing. For instance, a systematic review and meta-analysis found that mask-wearing cuts the incidence of COVID-19 by 53% overall. [26] [27] The efficacy may also be substantially higher, especially if certain types of masks are worn or under specific conditions and settings.

Contact tracing

Manual contact tracing via mandatory traveler health forms at New York City's LaGuardia Airport in August 2020.
The contact tracing app "Corona-Warn-App" Cwa home android.png
The contact tracing app "Corona-Warn-App"

Contact tracing is an important method for health authorities to determine the source of infection and to prevent further transmission. [28] The use of location data from mobile phones by governments for this purpose has prompted privacy concerns, with Amnesty International and more than a hundred other organisations issuing a statement calling for limits on this kind of surveillance. [29]

An unincentivized and always entirely voluntary use of such digital contact tracing apps by the public was found to be low [30] [31] [32] even if the apps are built to preserve privacy (which may however compete with alternative domestic apps that don't do so and can't always be used), leading to low usefulness of the software for pandemic mitigation as of April 2021. A lack of possible features, prevalent errors and possibly other issues reduced their usefulness further. [33] Use of such an app in general or during specific times is in many or all cases not provable or requirable.

Moreover, contact-tracing apps may be designed criteria (<1 metre; and > 15 minutes contact) insufficient for controlling danger. [34]

Information technology

Several mobile apps have been implemented or proposed for voluntary use, and as of 7 April 2020 more than a dozen expert groups were working on privacy-friendly solutions such as using Bluetooth to log a user's proximity to other cellphones. [29] (Users are alerted if they have been near someone who subsequently tests positive.) [29]

On 10 April 2020, Google and Apple jointly announced an initiative for privacy-preserving contact tracing based on Bluetooth technology and cryptography. [35] [36] The system is intended to allow governments to create official privacy-preserving coronavirus tracking apps, with the eventual goal of integration of this functionality directly into the iOS and Android mobile platforms. [37] In Europe and in the U.S., Palantir Technologies is also providing COVID-19 tracking services. [38]

In February 2020, China launched a mobile app to deal with the disease outbreak. [39] Users are asked to enter their name and ID number. The app can detect 'close contact' using surveillance data and therefore a potential risk of infection. Every user can also check the status of three other users. If a potential risk is detected, the app not only recommends self-quarantine, it also alerts local health officials. [40]

Big data analytics on cellphone data, facial recognition technology, mobile phone tracking, and artificial intelligence are used to track infected people and people whom they contacted in South Korea, Taiwan, and Singapore. [41] [42] In March 2020, the Israeli government enabled security agencies to track mobile phone data of people supposed to have coronavirus. According to the Israeli government, the measure was taken to enforce quarantine and protect those who may come into contact with infected citizens. The Association for Civil Rights in Israel, however, said the move was "a dangerous precedent and a slippery slope". [43] Also in March 2020, Deutsche Telekom shared aggregated phone location data with the German federal government agency, Robert Koch Institute, to research and prevent the spread of the virus. [44] Russia deployed facial recognition technology to detect quarantine breakers. [45] Italian regional health commissioner Giulio Gallera said he has been informed by mobile phone operators that "40% of people are continuing to move around anyway". [46] The German Government conducted a 48-hour weekend hackathon, which had more than 42,000 participants. [47] [48] Three million people in the UK used an app developed by King's College London and Zoe to track people with COVID-19 symptoms. [49] [50] The president of Estonia, Kersti Kaljulaid, made a global call for creative solutions against the spread of coronavirus. [51]

Health care

An army-constructed field hospital outside Ostra sjukhuset (Eastern hospital) in Gothenburg, Sweden, contains temporary intensive care units for COVID-19 patients. Ostra Sjukhuset COVID-19 Faltsjukhus.jpg
An army-constructed field hospital outside Östra sjukhuset (Eastern hospital) in Gothenburg, Sweden, contains temporary intensive care units for COVID-19 patients.

Increasing capacity and adapting healthcare for the needs of COVID-19 patients is described by the WHO as a fundamental outbreak response measure. [52] The ECDC and the European regional office of the WHO have issued guidelines for hospitals and primary healthcare services for shifting of resources at multiple levels, including focusing laboratory services towards COVID-19 testing, cancelling elective procedures whenever possible, separating and isolating COVID-19 positive patients, and increasing intensive care capabilities by training personnel and increasing the number of available ventilators and beds. [52] [53] In addition, in an attempt to maintain physical distancing, and to protect both patients and clinicians, in some areas non-emergency healthcare services are being provided virtually. [54] [55] [56]

Research and development

There are research-based developments that aim to mitigate COVID-19 spread beyond vaccines, repurposed and new medications and similar conventional measures.

Researchers investigate for safe ways of public transport during the COVID-19 pandemic. [57] [58]

Novel vaccine passports have been developed.

Researchers are developing face-masks which could be more effective at reducing SARS-CoV-2 spread than existing ones and/or have other desired properties such as biodegradability and better breathability. [59] [60] [61] [62] [63] [64] Some are also researching attachments to existing face-masks to make them more effective [63] or to add self-cleaning features. [63] The pandemic has increased efforts to develop such masks and some have received government grants for their development. [63]

Ventilation and air cleaners are also the subject of research and development. [65] [66]

Researchers report the development of chewing gums that could mitigate COVID-19 spread. The ingredients – CTB-ACE2 proteins grown via plants – bind to the virus. [67] [68]

On 23 April 2020, NASA reported building, in 37 days, a ventilator (called VITAL). [69] [70] On April 30, NASA reported receiving fast-track approval for emergency use by the United States Food and Drug Administration for the new ventilator. [71] As of March 2020, 26 manufacturers around the world have been licensed to make the device. [72] The COVID-19 pandemic increased the demand for oxygen concentrators. During the pandemic open source oxygen concentrators were developed, locally manufactured – with prices below imported products – and used, especially during a COVID-19 pandemic wave in India. [73] [74] Due to capacity limitations in the standard supply chains, some manufacturers are 3D printing healthcare material such as nasal swabs and ventilator parts. [75] [76] In one example, when an Italian hospital urgently required a ventilator valve, and the supplier was unable to deliver in the timescale required, a local startup received legal threats due to alleged patent infringement after reverse-engineering and printing the required hundred valves overnight. [77] [78] [79]

Living with COVID-19

This section is an excerpt from Endemic COVID-19.[ edit ]

COVID-19 is predicted to become an endemic disease by many experts. The observed behavior of SARS-CoV-2, the virus that causes COVID-19, suggests it is unlikely it will die out, and the lack of a COVID-19 vaccine that provides long-lasting immunity against infection means it cannot immediately be eradicated; [80] thus, a future transition to an endemic phase appears probable. In an endemic phase, people would continue to become infected and ill, but in relatively stable numbers. [80] Such a transition may take years or decades. [81] Precisely what would constitute an endemic phase is contested. [82]

Endemic is a frequently misunderstood and misused word outside the realm of epidemiology. Endemic does not mean mild, or that COVID-19 must become a less hazardous disease. The severity of endemic disease would be dependent on various factors, including the evolution of the virus, population immunity, and vaccine development and rollout. [81] [83] [84]

COVID-19 endemicity is distinct from the COVID-19 public health emergency of international concern, which was ended by the World Health Organization on 5 May 2023. [85] Some politicians and commentators have conflated what they termed endemic COVID-19 with the lifting of public health restrictions or a comforting return to pre-pandemic normality.

See also

Related Research Articles

<span class="mw-page-title-main">Pandemic</span> Widespread, often global, epidemic of severe infectious disease

A pandemic is an epidemic of an infectious disease that has a sudden increase in cases and spreads across a large region, for instance multiple continents or worldwide, affecting a substantial number of individuals. Widespread endemic diseases with a stable number of infected individuals such as recurrences of seasonal influenza are generally excluded as they occur simultaneously in large regions of the globe rather than being spread worldwide.

<span class="mw-page-title-main">Epidemic</span> Rapid spread of disease affecting a large number of people in a short time

An epidemic is the rapid spread of disease to a large number of hosts in a given population within a short period of time. For example, in meningococcal infections, an attack rate in excess of 15 cases per 100,000 people for two consecutive weeks is considered an epidemic.

<span class="mw-page-title-main">SARS</span> Disease caused by severe acute respiratory syndrome coronavirus

Severe acute respiratory syndrome (SARS) is a viral respiratory disease of zoonotic origin caused by the virus SARS-CoV-1, the first identified strain of the SARS-related coronavirus. The first known cases occurred in November 2002, and the syndrome caused the 2002–2004 SARS outbreak. In the 2010s, Chinese scientists traced the virus through the intermediary of Asian palm civets to cave-dwelling horseshoe bats in Xiyang Yi Ethnic Township, Yunnan.

<span class="mw-page-title-main">Contact tracing</span> Finding and identifying people in contact with someone with an infectious disease

In public health, contact tracing is the process of identifying people who may have been exposed to an infected person ("contacts") and subsequent collection of further data to assess transmission. By tracing the contacts of infected individuals, testing them for infection, and isolating or treating the infected, this public health tool aims to reduce infections in the population. In addition to infection control, contact tracing serves as a means to identify high-risk and medically vulnerable populations who might be exposed to infection and facilitate appropriate medical care. In doing so, public health officials utilize contact tracing to conduct disease surveillance and prevent outbreaks. In cases of diseases of uncertain infectious potential, contact tracing is also sometimes performed to learn about disease characteristics, including infectiousness. Contact tracing is not always the most efficient method of addressing infectious disease. In areas of high disease prevalence, screening or focused testing may be more cost-effective.

<span class="mw-page-title-main">Yuen Kwok-yung</span> Hong Kong microbiologist and physician

Yuen Kwok-yung is a Hong Kong microbiologist, physician, and surgeon. He is a prolific researcher, with most of his nearly 800 papers related to research on novel microbes or emerging infectious diseases. He led a team identifying the SARS coronavirus that caused the SARS pandemic of 2003–04, and traced its genetic origins to wild bats. During the COVID-19 pandemic, he acted as expert adviser to the Hong Kong government.

<span class="mw-page-title-main">Social distancing</span> Infection control technique by keeping a distance from each other

In public health, social distancing, also called physical distancing, is a set of non-pharmaceutical interventions or measures intended to prevent the spread of a contagious disease by maintaining a physical distance between people and reducing the number of times people come into close contact with each other. It usually involves keeping a certain distance from others and avoiding gathering together in large groups.

<span class="mw-page-title-main">COVID-19 pandemic</span> Pandemic caused by SARS-CoV-2

The COVID-19 pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), began with an outbreak of COVID-19 in Wuhan, China, in December 2019. It spread to other areas of Asia, and then worldwide in early 2020. The World Health Organization (WHO) declared the outbreak a public health emergency of international concern (PHEIC) on 30 January 2020, and assessed the outbreak as having become a pandemic on 11 March.

<span class="mw-page-title-main">COVID-19</span> Contagious disease caused by SARS-CoV-2

Coronavirus disease 2019 (COVID-19) is a contagious disease caused by the coronavirus SARS-CoV-2. The disease spread worldwide, resulting in the COVID-19 pandemic.

<span class="mw-page-title-main">Flattening the curve</span> Public health strategy

Flattening the curve is a public health strategy to slow down the spread of an epidemic, used against the SARS-CoV-2 virus during the early stages of the COVID-19 pandemic. The curve being flattened is the epidemic curve, a visual representation of the number of infected people needing health care over time. During an epidemic, a health care system can break down when the number of people infected exceeds the capability of the health care system's ability to take care of them. Flattening the curve means slowing the spread of the epidemic so that the peak number of people requiring care at a time is reduced, and the health care system does not exceed its capacity. Flattening the curve relies on mitigation techniques such as hand washing, use of face masks and social distancing.

Pandemic prevention is the organization and management of preventive measures against pandemics. Those include measures to reduce causes of new infectious diseases and measures to prevent outbreaks and epidemics from becoming pandemics.

Allison Joan McGeer is a Canadian infectious disease specialist in the Sinai Health System, and a professor in the Department of Laboratory Medicine and Pathobiology at the University of Toronto. She also appointed at the Dalla Lana School of Public Health and a Senior Clinician Scientist at the Lunenfeld-Tanenbaum Research Institute, and is a partner of the National Collaborating Centre for Infectious Diseases. McGeer has led investigations into the severe acute respiratory syndrome outbreak in Toronto and worked alongside Donald Low. During the COVID-19 pandemic, McGeer has studied how SARS-CoV-2 survives in the air and has served on several provincial committees advising aspects of the Government of Ontario's pandemic response.

Planning and preparing for pandemics has happened in countries and international organizations. The World Health Organization writes recommendations and guidelines, though there is no sustained mechanism to review countries' preparedness for epidemics and their rapid response abilities. National action depends on national governments. In 2005–2006, before the 2009 swine flu pandemic and during the decade following it, the governments in the United States, France, UK, and others managed strategic health equipment stocks, but they often reduced stocks after the 2009 pandemic in order to reduce costs.

In epidemiology, a non-pharmaceutical intervention (NPI) is any method used to reduce the spread of an epidemic disease without requiring pharmaceutical drug treatments. Examples of non-pharmaceutical interventions that reduce the spread of infectious diseases include wearing a face mask and staying away from sick people.

<span class="mw-page-title-main">Transmission of COVID-19</span> Mechanisms that spread coronavirus disease 2019

The transmission of COVID-19 is the passing of coronavirus disease 2019 from person to person. COVID-19 is mainly transmitted when people breathe in air contaminated by droplets/aerosols and small airborne particles containing the virus. Infected people exhale those particles as they breathe, talk, cough, sneeze, or sing. Transmission is more likely the closer people are. However, infection can occur over longer distances, particularly indoors.

Software for COVID-19 pandemic mitigation takes many forms. It includes mobile apps for contact tracing and notifications about infection risks, vaccine passports, software for enabling – or improving the effectiveness of – lockdowns and social distancing, Web software for the creation of related information services, and research and development software. A common issue is that few apps interoperate, reducing their effectiveness.

<span class="mw-page-title-main">United States responses to the COVID-19 pandemic</span>

The United States' response to the COVID-19 pandemic with consists of various measures by the medical community; the federal, state, and local governments; the military; and the private sector. The public response has been highly polarized, with partisan divides being observed and a number of concurrent protests and unrest complicating the response.

<span class="mw-page-title-main">United Kingdom responses to the COVID-19 pandemic</span>

The United Kingdom's response to the COVID-19 pandemic consists of various measures by the healthcare community, the British and devolved governments, the military and the research sector.

<span class="mw-page-title-main">Chinese government response to COVID-19</span>

During the COVID-19 pandemic in mainland China, the government of China under CCP general secretary Xi Jinping's administration pursued a zero-COVID strategy to prevent the domestic spread of COVID-19 until late 2022. Aspects of the response have been controversial, with the zero-COVID approach being praised and the government's lack of transparency, censorship, and spread of misinformation being criticized. The government abandoned its zero-COVID policy on 7 December 2022.

<span class="mw-page-title-main">Zero-COVID</span> COVID-19 elimination strategy

Zero-COVID, also known as COVID-Zero and "Find, Test, Trace, Isolate, and Support" (FTTIS), was a public health policy implemented by some countries, especially China, during the COVID-19 pandemic. In contrast to the "living with COVID-19" strategy, the zero-COVID strategy was purportedly one "of control and maximum suppression". Public health measures used to implement the strategy included as contact tracing, mass testing, border quarantine, lockdowns, and mitigation software in order to stop community transmission of COVID-19 as soon as it was detected. The goal of the strategy was to get the area back to zero new infections and resume normal economic and social activities.

<span class="mw-page-title-main">Endemic COVID-19</span> Theoretical future stage of COVID-19

COVID-19 is predicted to become an endemic disease by many experts. The observed behavior of SARS-CoV-2, the virus that causes COVID-19, suggests it is unlikely it will die out, and the lack of a COVID-19 vaccine that provides long-lasting immunity against infection means it cannot immediately be eradicated; thus, a future transition to an endemic phase appears probable. In an endemic phase, people would continue to become infected and ill, but in relatively stable numbers. Such a transition may take years or decades. Precisely what would constitute an endemic phase is contested.

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