Table for Six (Reopening Options)

Comparing risks and assumptions for pandemic next steps

My Facebook news feed is currently all custom emojis and opinions on how to reopen local economies after COVID-19 lockdowns. We could use more tools to understand one of those. I made a table to compare potential risks, rewards, and assumptions for different policy options, followed by analysis.

This debate matters. We’re all paying the price of a delayed federal response and incompetent management. Lack of testing and contact tracing in February resulted in uncontrolled COVID-19 transmission. So we resorted to lockdowns. We’ve lost a reported 89,540 Americans. While elders have suffered most, middle-aged and young people have also faced serious infections and longer-term complications. Meanwhile, the lockdowns are causing significant economic harm as well as increased rates of anxiety and depression. Our decisions for next steps must incorporate all of these understandings. Because losing like we are right now sucks.

In the table, rows represent approaches using different levels of protective measures, from most to least. These measures include wearing masks, washing hands, and avoiding close contact with others, especially indoor groups. The rows also alternate between using or not using widespread testing, contact tracing, and quarantining of infected people (TCTQ). The columns represent different types of health: economic, human related to the virus, and other types of human health. They are also split into two groups: low-range infection fatality rate (IFR) and high-range IFR. The emojis denote desirable/improving outcomes (green smiles), neutral outcomes (yellow neutral faces), and undesirable/deteriorating outcomes (red frowns).

MAIN ASSUMPTIONS AND CONTEXT:

COVID-19-related health outcomes depend on virulence and transmission. Infection mortality rate (IFR) represents the average risk of death if infected and is the best indicator of virulence. The effective reproduction number (Rₑ) represents the average number of people infected by one contagious person over a specific time frame.

COVID-19 infection mortality rate (IFR) estimates vary. IFR accounts for a variety of variables and is distinct from case fatality rate (CFR). As of mid-May, different epidemiologists have calculated the COVID-19 IFR as anywhere between 0.12 and 2.1%. A value of 0.86% for the U.S. (based on April New York City antibody testing) is likely the most accurate so far. Those tests were less prone to false positives due to relatively high prevalence. A recent meta-analysis found a global IFR range of 0.49 to 1.01%. There is general agreement that risk increases significantly with age and pre-existing medical conditions. Age-based IFR estimates will hopefully be available soon. Regardless, an overall IFR in the lower end of the possible range would warrant less restrictive measures than an IFR on the higher end of the range.

Protective measures reduce the Rₑ. Values over 1.0 indicate growth of an epidemic. Social distancing, frequent testing, contact tracing, and quarantining infected people reduces it, as evident in countries with much fewer cases and deaths than us as well as in The White House.

Uncontrolled transmission of COVID-19 kills people AND economies. Beware false frames of human and economic health in opposition. Infections and deaths harm individuals, communities, and economies. A recent University of Cambridge study notes that sickness and death hurt production. People also seek shelter when a lot of others are suffering or hospitals are overwhelmed.

Long-term lockdowns also cause great economic harm. People need to work to earn a living. The U.S. economy likely wasn’t built to withstand longterm essential-only business operations. The question of what a more resilient economy might look like is also worth exploring.

There are degrees of laxness. We can’t expect to fully return to our pre-COVID lifestyles for a long time. The term “lax” here refers to regularly being around other people while still taking basic precautions to prevent transmission (e.g., avoiding large indoor crowds, not playing spin-the-bottle).

Precise tools are preferred when available. Widespread testing, contact tracing, and quarantining are more precise than lockdowns. Faster, cheaper, less painful, home-ready tests (ideally coming soon) will help.

The time frame involved is between now and the fall. It’s reasonable to expect somewhat reduced COVID-19 viability in the summer. Unfortunately, a possible second wave in the fall or winter could be exacerbated by flu co-morbidity. Subsequent increases fatality rates would warrant extra precautions and (if severe enough) additional lockdowns. In the longer term, more effective treatments would lower the IFR. Likewise, a vaccine or increased herd immunity would lower the Rₑ.

Most Americans currently favor staying home as much as possible and maintaining use of other strong protective measures. Partisan differences appear small. Protestors demanding aggressive reopening at state capitals and (anecdotally) in my Facebook feed have been mainly politically conservative.

People care a lot about these policy decisions. Many are hurting. It’s key to model respectful engagement and provide tools to help people understand what’s going on. Otherwise frustrations could lead to violence.

WHAT THE TABLE DEPICTS:

Different combinations of protective measures and IFR values lead to significantly different outcomes. A high-range IFR limits our options. Extended lockdowns would be necessary for values high enough to derail the work force. Let’s hope that’s not the case now or in potential future waves. An IFR near that calculated for NYC would likely warrant strong measures by all plus widespread testing, contact tracing, and quarantining of sick people. Lax measures by all or even just by lower-risk individuals would likely produce uncontrolled outbreaks and tragic economic AND human health results.

In contrast, low-range IFR values produce much lower death tolls, including during significant outbreaks. This is what Drs. Dan Erickson and Artin Massihi misleadingly presented as fact in April. For a low-range IFR there could be four acceptable policy options:

• Strong measures by all + TCTQ would result in effectively controlling infections. That would likely increase consumer confidence (e.g., use of the healthcare system for non-COVID-19 purposes).
• Strong measures by all would still be fairly effective in controlling infections.
• Lax measures by low-risk + TCTQ might promote the most economic health, while also supporting quality mental health outcomes.
• Lax measures by low-risk people might work okay, though pockets of uncontrolled outbreaks could require more restrictive measures.

TAKE-HOMES:

In case of a moderately high-range IFR, there is only one acceptable medium-term option: using every available tool other than extended strict lockdowns to minimize transmission. Short-term lockdowns could still be necessary in areas with major spikes of infections and deaths. These kinds of approaches could also be required next winter should there be a nasty second wave.

In case of a low-range IFR, we have more choices. But we currently lack conclusive evidence of it being low. Demanding lax approaches thus appears reckless. Simply assuming it’s low is akin to expecting to be greeted as liberators in Iraq. We can’t afford to be that wrong again. Nobody wins if relaxed restrictions produce uncontrolled outbreaks that also destroy the economy. As notes Linus Wilson (University of Louisiana at Lafayette - College of Business Administration), “unless IFR rates are much lower than the expected scenario, large economic disruptions as part of a social distancing campaign to reduce virus spread will be justified.”

A middle-range IFR is also possible (though not depicted). This would warrant a more cautious approach than a low-range IFR while allowing more flexibility than a high-range one.

Based on the data we DO have, it makes sense to proceed with caution. Specific responsible next steps include:

• Scaling up testing and contact tracing
• Maintaining precautions, particularly for at-risk populations (e.g., providing healthcare and other essential workers with proper PPE)
• Increasing national and international consistency in reporting infections and deaths to better know what is and isn’t working
• Sharing this article with curious friends and policy-makers