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Emerging from Plague: Thinking Ahead

By Shlomo Maital

With many nations still weeks from the ‘apex’ (the peak number of COVID-19 cases), it seems premature to discuss what the press and experts call ‘exit’ strategies – the period AFTER the plague. The word itself is wrongheaded. Exit strategies are what startups do, when they succeed in creating value and need to capture the wealth and return it to their investors and founders. Usually, by acquisition or issuing shares and selling them.

We do not seek an ‘exit’ strategy. We need an ‘emergence’ strategy, when we come out of our tunnels and rabbit holes and resume our regular lives. Words matter. There is no ‘exit’ from COVID-19, because it will remain endemic for a long time. There is ‘emergence’…with great caution.

How best can this be done? How should our governments be planning emergence?

Here are some wise thoughts by Prof. Ron Balicer, a person with whom I’ve worked, Chief Innovation Officer at Israel’s Clalit Health Services (a large HMO) and a member of the Health Ministry’s Epidemic Management Team. His article was published in the daily Haaretz newspaper.

“Mathematical models and past experience show that the spread of infection in communities living in overcrowded conditions can spark a renewed and serious outbreak among all segments of society. From an epidemiological perspective, Israel’s population (as well as, to a large extent, that of the Palestinian Authority) constitutes interconnecting “communicating vessels” with immediate collateral impact.

“In the current setting, the most stable and reliable marker of population-based trends in disease dissemination is the trend in the numbers of severely ill and respirator-aided Covid-19 patients. However, this marker lags behind the real-time spread by several weeks. If we continue to see that this marker is stabilizing – a collective sigh of relief will be heard. In the meantime, we must not wait for absolute certainty before planning the next phase of contending with this crisis and its attendant closure: the exit strategy.

“I propose two preconditions for initiating this strategy:   The first is a significant halt in the exponential rate of the disease spread, and the availability of a substantial number of free beds in intensive care units, which will serve as the buffer and allow a margin of error to prevent a collapse should easing of the lockdown spur a sudden increase in infections.   Let’s use some numbers as an illustration: In the optimistic scenario in which there are up to 100 seriously ill or respirated people in Israel on the eve of Passover, the distance between where we are now and the point of health system insufficiency is 4-5 doublings of the number of people needing artificial respiration. In recent weeks we’ve seen that the doubling time is three days, with faster rates in some localities.

“The second condition required before embarking on that strategy is to obtain a real-time intelligence assessment, detailed and updated, regarding the rates of infection among different communities. This is a precondition for resorting to a rapid intervention vis-a-vis every new patient, as is happening in countries that have managed to successfully curb the epidemic to date.

       “In other words, there needs to be an efficient system of conducting lab tests for Covid-19 among a wide swathe of the population, in order to exercise an effective exit strategy. To that end, Israel is hopefully gaining what will be an exceptional per-capita testing capacity, even in comparison to the advanced countries. The 30,000 daily tests we hope to be able to conduct in a few weeks’ time should be conducted dynamically and judiciously in order to facilitate this intelligence assessment.

“An exit strategy requires a change: a transition from social distancing and full lockdown enforced on the entire population in a sweeping and non-selective manner, to a new status quo. This new routine could be based on three components: a fast and focused effort to locate and tackle infected individuals; a differential and dynamic lockdown policy among targeted communities; and designated policies for allowing recovered immune patients to return to normal life and take a continuously increasing role in sustaining the economy.

“All this needs to be done while adapting the economy to working remotely with strong delivery services, to daily conduct based on social distancing and environmental hygiene in every workplace, and to continued construction of medical infrastructure, with maximal protection of medical teams.

“As part of the new status quo, the older population will remain as isolated “islands” within each community for a longer period, having its physical, emotional and social needs met on a daily basis.

[“There are several components –] The first component involves the efficient and determined tracking down of newly infected people and their rapid removal from the infective pool. This demands a rapid “closing of the circle” capacity. The multi-stage process of locating people suspected of being infected and having them tested for Covid-19, the rapid quarantine of sick people removed from home, an epidemiological investigation and a quick isolation of their contacts – all this must be accomplished with speed and precision. Moreover, it must be done in large numbers of cases and contacts.

For this condition to be met, a combination of capabilities – which at present are suboptimal – must be achieved. These include extensive and carefully thought-out testing of all people who have been in contact with the new cases; the ability to obtain results quickly for those who tested positive, and their removal from their families to hotels or other facilities; both manual and electronic epidemiological investigation, contact tracing and their quarantine; and firm enforcement of social-distancing instructions, among all segments of society.

“The second component is a geographically differential lockdown/quarantine policy, dynamically updated according to the available data. Communities in which there is persistent transmission of the virus, and those with individuals who are particlarly vulnerable, must remain under a stricter lockdown, whereas communities in which transmission has effectively been mitigated can enjoy a continued easing of restrictions.

“The country can be divided into sub-regions. Imagine that one day the radio announces that areas A, B and D can go to work from now on, whereas area C (i.e., Jerusalem or Rahat) is still to be confined to home. On another day, area A might be asked to reinstate a four-week lockdown, in view of ensuing infection. Obviously, such a policy won’t completely prevent “leakage” between areas and communities, but it will significantly head it off, and with the other components in place, this may be sufficient.

“In order to facilitate and supervise such a policy, an ongoing process of real-time intelligence-gathering must be established, including the continual monitoring of self-reported symptoms and continuous screening for infected people, in order to detect potential outbreaks as early as possible.

“The third component: Once serologic blood tests will become largely available, we will be able to conduct mass testing and define a growing number of recovered immune individuals. This group will assume an increasing role in re-operating businesses with few restrictions. Moreover, older people who got sick and recovered could also return to a “new normal” routine.

“In my view, easing of the closure will take place as a continuous, gradual process of experimentation and re-assessment, in cycles of several weeks each. In each cycle, significant restrictions will be lifted, followed by a tense watchful waiting period of several weeks, required to evaluate its impact on the dissemination rates. If the doubling time does not accelerate significantly, and the safety margin of available intensive care beds has not been reduced to the danger level, further easing of measures can be then implemented.”

Blog entries written by Prof. Shlomo Maital

Shlomo Maital

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