COMMENTARY

Doomsday Scene: COVID-19, Flu, Measles, & Winter. Here's Our Plan

Arthur L. Caplan, PhD

June 26, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

Despite flare-ups of COVID-19 in the US and other nations, there is a lot of optimism floating around that we are going to get out of this pandemic with the discovery and distribution of a vaccine by late this year or early 2021. But I highly doubt that a vaccine "magic bullet" will appear that quickly, because of the need for careful, large-scale clinical research; manufacturing and distribution challenges; and uncertainty about the efficacy and durability of a vaccine. 

Further, COVID-19 is not the sole challenge we face. Flu and measles are likely to make our lives very miserable by the end of the year as kids miss their shots and people resist getting flu vaccinations. We need more debate about how to get ready for a perfect storm of infectious disease. 

I asked my colleagues at NYU Grossman School of Medicine in pediatrics, infectious disease, public health, and bioethics for their ideas about managing a "doomsday" scenario — which I hope never to see but nonetheless think needs to be discussed and debated. Here are 10 important areas we need to think about.

1. Data Monitoring and Surveillance — Get the Numbers

Monitoring of infection rates and data surveillance must be ongoing and transparent. Data should include:

  • Syndromic sentinel surveillance for the area (number of patients presenting to emergency departments with influenza-like symptoms, which could be COVID-19 or flu)

  • Tests on sewage and residual blood from emergency departments

  • Number tested for COVID-19 and number positive

  • Number tested for flu and number positive

  • Number of nursing home outbreaks detected by area (COVID-19 and flu)

  • Number of measles cases

2. Contact Tracing

  • Local health authorities should establish and implement strategy

  • Must be mandatory, with fines for noncompliance

  • Not GPS-based, to help protect privacy and gain public support

  • Essential it is separate from police/ICE to enable outreach to undocumented citizens and those with legal residency status concerns.

3. Establishing Policies

Institute policies for housing and protecting the vulnerable, including those who are homeless, cognitively impaired, and technology dependent (including those who resist masks).

Formulate policies for distributing flu shots and any emerging COVID-19 vaccine effectively. Policies to cover the cost of testing, treatment, and counseling must be established, along with financial allotments for lost income, etc.

4. Quarantine and Isolation

Some parts of the country have seen little to no COVID-19 presence, and thus should not be subject to quarantine/social isolation. A national policy, based on public metrics, must be established for exempting those areas. 

Areas that see high infection and hospitalization rates need to be prepared to return rapidly to strict quarantine/social isolation practices, according to national metrics.

Some areas may institute quarantine only for high risk, nonessential workers. This would permit low-risk populations, such as children and young adults, to leave their homes if they are properly protected with masks and flu vaccination; staggered school and recreation hours to minimize crowding would be implemented to further reduce risk. The lower-risk populations must protect older and other at-risk people they live with by isolating, distancing, using masks, and practicing good hygiene.

In addition to stay-at-home orders, winter in many parts of the country means more time indoors, which can increase risk for domestic conflicts. Initiate and publicize broadly an extensive education campaign about resources for those who experience, or are at risk of experiencing, abuse or intimate partner violence.

5. Sharing Information

The National Academies of Medicine should establish a forum of trustworthy, independent science and medical experts to provide daily briefings online about what is currently happening and what is known/not known. The forum should serve as a trusted source for the media.

Numbers of infected, hospitalized, and deceased should be published nationally and state-by-state, with accuracy of demographic information certified by the CDC.

Promulgate expert advice about pregnancy and breastfeeding, and how to both protect kids who are too young to wear masks and prevent them from spreading a virus to others. Distribute clear, expert advice about what to do if you're at home or work and feel ill.

6. Planning Ahead for States and Hospitals/Hospital Systems

States must prepare a large stockpile of high-quality PPE, as well as therapies including ventilators, dialysis equipment, etc. This should be predeposited regionally to permit rapid deployment based on urgency and need, without regard to state boundaries, cost, or unexplained federal seizure.

States must create nursing home/long-term care/home care strategies that plan for patient transfers; PPE for staff; resident prophylaxis; special isolation; equipment for televised visits and protective gear for permitting in-person family visits; and rapid, frequent seropositive testing. Policies must be established for discharging to homes patients with COVID-19, flu, measles, and other conditions. 

States must establish and publicize criteria for school closures, including daycare/afterschool programs.

Establish nationwide consensus on how to fill out death certificates to accurately reflect COVID-19 deaths, including "probable" cases.

Hospitals must create clear, transparent plans in place for what to do if a case of infectious disease is detected in staff or residents.

Formulate clear policies about non-COVID-19 health services. Which will continue, and where? Consider establishing flu- and COVID-19-only medical units/facilities.

Encourage crash-funding of research to determine which techniques are most effective at getting people to follow guidelines (wearing masks, distancing) and get vaccinations.

Maximize the use of telemedicine as well as other virtual interaction (online banking, online shopping, etc).

7. Daily Life

Masks must be worn in public and in close proximity to others; protective shields should be used at workplaces, in buildings, etc.

Ensure that water in public housing, on reservations, in public toilets, and in shelters is in good repair and widely available so that people can frequently wash their hands and maintain other recommended hygiene.

Grocery stores and pharmacies should continue to reserve/implement special hours for seniors and those with health-related reasons to minimize social contact.

Program or physically monitor elevators to control the number of people who can enter.

HEPA air filtration systems should be installed in buildings, schools, daycare centers, etc. Negative-pressure systems should be also be considered, especially for public gathering places such as community centers and libraries.

8. Schools

Formulate daycare/afterschool policies to allow both their operation and to protect older/vulnerable teachers and support personnel, as well as older relatives of children. Colleges and universities should be transparent about plans to maintain student safety when they open, and promulgate criteria for closures.

9. Public Transportation

Continue/implement efforts to clean and maintain public transportation. Provide hazardous duty pay for drivers, cleaners, other frontline essential employees. Set maximum occupancy and require physical distancing.

10. Travel

No cruises or train excursions, and close smoking stations in airports. The CDC should issue and publicize guidance on "safe" vacationing and other nonessential travel.

COVID-19 in combination with flu and measles would incapacitate our healthcare system and break our economy. Perhaps that will not happen. We ought to be planning as if it will.

Dr Caplan co-directs an advisory group on sports and recreation for the US Conference of Mayors. He helped develop an ethical framework for distributing drugs and vaccines for J&J and is a member of the WHO advisory committee on COVID-19, ethics, and experimental drugs/vaccines. All of the above are unpaid.

Arthur L. Caplan, PhD, is Director, Division of Medical Ethics, New York University Grossman School of Medicine, New York City

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