When Will We Know If Reopening States Has Worked or Backfired?

• A new poll found that 58 percent of respondents say the U.S. will move too quickly to reopen, while 32 percent say it will take too long to loosen restrictions.
• Regardless of attitudes on reopening, it remains to be seen how relaunching the economy will go from a public health standpoint.
• Experts say that as people interact more, cases will go up, but it’s unclear if there will be another surge in cases.

It seems like most businesses are reopening as the pandemic continues — or at least trying to.

But how will we know if reopening businesses during the COVID-19 pandemic is a good idea?

An NBC News/Wall Street Journal poll found that 58 percent of respondents said the United States will move too quickly to reopen, while 32 percent said it would take too long to loosen restrictions.

A Gallup poll found that 58 percent of U.S. adults are completely or mostly isolating themselves. The number declined from 75 percent between March 30 and April 5, the week before.

Another poll found 73 percent of Americans think there’s a shortage of coronavirus tests available in the country.

Regardless of attitudes on reopening, it remains to be seen how relaunching the economy will go from a public health standpoint.

Healthline gathered a few experts to weigh in:

• Michael Greenberger, JD, founder and director of the University of Maryland Center for Health and Homeland Security
• Amira Roess, PhD, MPH, professor of Global Health and Epidemiology at George Mason University
• Rodney E. Rohde, PhD, professor in the College of Health Professions who focuses on public health microbiology at Texas State University
• Dr. Thomas A. Russo, professor and chief of infectious disease at the University of Buffalo Jacobs School of Medicine and Biomedical Sciences

What markers will we be using as indicators that a state is ready to open?

Roess: We want to keep track of the number of cases, deaths, recovered, exposed, and number of contacts of confirmed or suspected cases. We also need to keep track of what healthcare resources are available.

Also, we need to make sure that we have trained individuals who can respond and conduct public health monitoring, contact tracing, and other related activities.

Rohde: I expect states will be looking at several markers. The White House Plan says “they first need to see evidence of a downward trajectory of documented cases and influenza-like illnesses within a 14-day period.”

I would agree with that assessment, along with a strong testing strategy that utilizes the most accurate testing platforms available conducted by properly credentialed medical and public health laboratory professionals.

Russo: I think there’s no question that as people start to interact more, there’s going to be a bump in cases. We want to crank our testing up first and get that baseline set. If that baseline is set, then new cases can be pinpointed to reopening.

I think at the end of the day, the metric is going to be a bump in new cases and a bump in hospitalizations, and a bump in deaths, assuming you hit a baseline before you start opening things up. The questions are: What is the threshold? How much are you going to tolerate?

What are different avenues for reopening that states will consider, and how might they vary by state?

Greenberger: There are two state policy variants. One reopening variant adopts a cautious approach and only goes into effect when the number of infections and deaths are clearly trending downward over a set period of time. The other variant is to open without concern for data: just reopen.

New York represents the first variant that’s dependent on data. Texas and Georgia represent those states that will open without real reference to data.

Roess: Some states are prioritizing opening up sectors of the economy that can reopen while maintaining social distancing. Retailers, malls/shopping centers, parks, and restaurants have been among the first nonessentials to open in some states.

Rohde: I think that much of the different avenues for reopening states will depend on the number of cases in certain regions, and even counties. To my understanding on the current case situation, there are several states (maybe around 10) that have around 1,000 cases with only a steady, low number each day. So, in those types of situations we may see some states open sooner than others. I look at this virus as a “smoldering pandemic” with the ability to become a wildfire if the right fuel is in place.

What will indicate if a state has opened too soon? 

Greenberger: In terms of data for those states pressing a hard reopening, it is for the most part too soon to tell whether there will be increased infections and deaths, because of the amount of time it takes for symptoms of COVID to manifest themselves: anywhere from 10 days to 2 weeks.

The early data generally point to a substantial increase in infections. The informed guess is that if infections and deaths skyrocket, governors supporting early and arbitrary reopenings will have to do an about-face and begin a closing down process.

Roess: If we start to see a surge in cases and local healthcare facilities get overwhelmed, then we will likely see states having to scale back down, and possibly even shutting down again.

Rohde: Caseloads and other healthcare data that shows a rise in cases and a lowering of bed capacity (general and ICU).

When reopening, are there measures put in place so we can dial back without going back to complete lockdown, or is it more all or nothing?

Roess: We will need to both monitor the extent of reopening and how it correlates with numbers of cases. We may need to scale back if we find that we just don’t have the resources to support testing, contact tracing, and other public health monitoring activities.

Likewise, if the healthcare system cannot handle a surge in cases, then it will be necessary to scale back.

Rohde: I don’t think anyone can promise that we will not go back to a “shelter in place” or even stricter measures. What’s most difficult for people who haven’t been trained or educated in public health and healthcare epidemiology around outbreaks is that sometimes these very measures can work really well and the general public thinks “we” overreacted.

It’s the nature of the business with microbes. If we do too little or too much, we may never truly know if we had the outcome we wanted because of those measures. It’s a difficult and fine line we must walk.

How will we be able to tell if something needs to be dialed back?

Roess: It’s critical to have active public health monitoring and testing, particularly at each phase of reopening. If you don’t have active public health monitoring, then by the time you realize there’s a problem you will be faced with an inundation of severe cases to hospitals and a surge in deaths.

Russo: If it goes flat, or there’s a small increase, we may not have to dial back. If we start to significantly fill up our hospitals again… I think then we have to start to take a hard look at reinstituting some of these measures.

We don’t want to get into a situation where we run out of beds.

Assuming states reopen in the summer, how will flu season factor in the fall?

Roess: Part of our calculations must include considerations for what impact flu season may have on COVID-19. We are operating with limited data because this virus is still new, and we don’t know if there is a seasonality pattern to COVID-19 transmission.

There are some basic assumptions that we can make regarding what an active flu season might mean for COVID-19. For example, individuals with flu or other respiratory infections can be more vulnerable to COVID-19. We want to avoid dual infections, and that means that we need to have protocols in place for how to avoid flu outbreaks. 

Rohde: We will need to reemphasize the need for flu vaccine and strong respiratory viral panel testing to understand the epidemiology of the types and magnitude of virus circulation via national (and global) surveillance.

Do you think a potential flu season second wave shutdown will be more easily enacted after all we’ve been through since March?

Roess: Future shutdowns can only be made easier if we truly learn from what we’ve encountered and plan accordingly.

In addition to improving public health monitoring, as I’ve indicated, we should also plan for how to support childcare providers and K-12 institutions, recognizing that much of the workforce has children and in turn relies on these institutions.

Rohde: I would hope that we as a nation are prepared to do what’s best for the health of vulnerable populations. However, as we are seeing with some civil unrest around employment and freedoms to move about the country to do what people want to do, I’m not certain that it will be “more easily enacted” a second or subsequent times. I believe it will come down to strong science communication.

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