State-Level Risk Assessments Critical for Reducing COVID-19 Measures

In the context of COVID-19, state-level decision-makers should conduct risk assessments to better understand how to move from strict social distancing measures to a staged reopening phase, according to a report from the Johns Hopkins Center for Health Security.

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Most states have adopted social distancing measures to reduce the spread of COVID-19, with nonessential businesses, schools, and outdoor spaces being shut down to mitigate the impact of the virus. The process of reopening these community settings will look different in each state, the report authors said.

“Although no states are ready to lift physical distancing measures, there is immense pressure to get back to business as usual, and these developments have prompted questions around how to reopen in individual states when it becomes safer to do so,” researchers stated.

“It will be essential for each state to make informed decisions about how to carefully move from a strict physical distancing phase (Phase I) to a staged reopening phase (Phase II) and to communicate that rationale clearly.”

Risk assessments will play a key role in reopening, and as part of these risk assessments, state-level leaders should consider the likelihood and consequences of relaxing social distance measures.

“Assessing the risks of easing social distancing measures and restarting parts of the economy requires a measurement of the likelihood of increased transmission and the consequences of that transmission,” the report stated.

“Likelihood in this case means the probability that reopening a business, school, or other organization where people congregate will cause significantly increased transmission. Consequence is the impact that increased transmission could have on individuals or communities if a business, school, or other organization reopens or eases social distancing measures.”

The report authors provided high-level risk assessments for seven categories: nonessential businesses, schools and childcare facilities, outdoor spaces, community gathering spaces, transportation, mass gatherings, and interpersonal gatherings.

The group assessed each of these categories along three dimensions, including contact intensity, number of contacts, and the degree to which activities are considered to be modifiable to reduce risk.

Researchers noted that schools and childcare facilities may pose special challenges to reopening. These institutions have a high contact intensity, and a low-to-medium modification level. While evidence has shown that children are less vulnerable to severe illness from COVID-19 than adults, the team pointed out that children’s role in transmitting the virus is still unknown.

Additionally, some children may have underlying conditions that will prevent them from returning to schools if they do reopen, and adults who staff schools and childcare facilities may be at risk for severe illness. These factors could work against reopening.

“In order to better understand the role of children in transmission, studies reconstructing transmission chains are needed, as are studies seeking to correlate viral load to infectiousness. Governors should work with their state public health departments to make this research a priority,” researchers said.

In contrast, outdoor spaces – like pools, parks, and beaches – are less likely to result in transmission than indoor spaces and activities, and seem to carry the lowest risk.

Businesses and sectors with low contact intensity, low numbers of contacts, and a high ability to modify operations to mitigate risk will be safer to reopen sooner than those with high contact intensity and high contacts.

Researchers noted that states should consider initiating the reopening process only when they have met four criteria: when the number of new cases has declined for at least 14 days; rapid diagnostic testing is sufficient to test, at minimum, all people with COVID-19 symptoms; the healthcare system is able to safely care for all patients; and there is sufficient public health capacity to conduct contact tracing for all new cases and their close contacts.

Governors should also consider reopening in phases separated by two to three weeks, the authors said.

“After each phase of reopenings, state public health officials should review the numbers of new COVID-19 daily case counts, hospitalizations, and deaths carefully, along with other syndromic surveillance tools. The results of reopening decisions will take two to three weeks to be reflected in those numbers,” the team stated.

“If case counts, hospitalizations, and deaths go up in that time, further actions in reopening should be paused, and steps should be taken to get control of the rising numbers.”

Ultimately, reopening businesses and community settings will vary from state to state, and will require leaders to assess the risks involved with reducing physical distancing measures.

“These decisions should be made carefully and thoughtfully to limit the risk of disease resurgence. Reopening of businesses is only one step among many that will need to be considered on the path to recovering from this pandemic,” the report concluded.