Indicators to consider before thinking at reopening a country post COVID
The intent of this document is to highlight what the indicators are that decision makers have to take into account before deciding on the right moment to reopen a country post COVID. This document will therefore not contain a specific date but rather indicates what are the principled conditions that need to happen before reopening. The document is based on the experience of Italy, the first western European country stricken by the disease. Three different phases are analysed: the beginning, the mid-term, and the long term. The hope is that what Italy has learned can be useful to other countries that are currently starting to face COVID. As in the previous articles, “About the COVID learnings in Italy” and “About the 9.5% COVID19 lethality observed in Italy”, this document follows the spirit of blameless culture so it is not “indicting any individual or team for bad or inappropriate behaviour”. Data used for this analysis is aggregated online and accessible to anyone at https://tinyurl.com/covid-italy.
Author: Antonio Gulli, Contributors:Sim Bamford, Onofrio Petragallo, Reviewers: Andrea Fedele
Phase 1: the beginning of the epidemic
The current phase is the beginning of the epidemic. This section highlights six different indicators which have to be taken into account before declaring the end of phase 1. The following part of this section describes the current situation in Italy, 31th March 2020.
Number of deaths has exceeded 13,000, with a lethality conditioned to test above 11.9%. In less than two months the number of deaths exceeded 13,000 people, with the proportion of those people who tested positive for the virus going on to die rising above 11.9% (doubling the reported 5.8% in Hubei). Every day we have 600–1000 new deaths.
The impact of COVID in Italy has been devastating. Therefore, it is mandatory to put strong and principled strategies in place for avoiding a recurrence during the next few months.
Total number of positives has exceeded 110,000 with about 80,500 people still sick. In less than 2 months more than 110,000 people have been tested positive to COVID, and 75% of them are still sick and fighting the disease. Only about 12% of sick people have recovered so far, and 11.5% are dead. Every day about 4000–6000 new positives are discovered.
1st indicator: As a single positive can restart a new wave of the epidemic, it is mandatory to stay at home until the new daily positive is zero for at least 14 days in a row. Only recovered people with antibodies can circulate as they are immunized.
2nd indicator: As a single positive can restart a new wave of epidemic, it is mandatory to remain at home until it is fully understood what the evolution of current positives is. Only recovered people with antibodies can circulate as they are immunized.
Test coverage increases but a significant number of new positives are discovered daily. Italy is progressively increasing the number of tests per day exceeding 477.000 tests in total. Up to date 21% of people are positives conditioned to the test and about 4000–6000 new positive are identified daily indicating the COVID is still not fully contained.
It has been estimated that 60% of people who are positive for the virus remain asymptomatic. Currently, there is no policy in place to test this part of the population. However, it is clear that testing the asymptomatics has been instrumental in containing the contagion in other countries such as Korea. Besides that, identifying the people who developed COVID antibodies are critical for maintaining the country’s stability, offering assistance to sick people and to people who might be infected in the future, and for keeping the economy going.
It will be necessary to do fast tests on a large part of the population. Trying to actually understand how many people have been affected by COVID and how many haven’t. This will be necessary to understand also how many people are still affected by COVID, to limit their movements. Many companies are creating fast tests, but the important thing will be to be able to make these tests available to as many people as possible.
It is possible to find out through plasma whether a person has developed antibodies to COVID or not.
3rd indicator: As a single positive can restart a new wave of pandemic, it is mandatory to remain at home until the tests cover a significant part of the population and the positives are zero for several days in a row. This test must include a statistically significant part of the currently untested.
4th indicator: Only those recovered with antibodies can circulate as they are immunized. Some sources called this an “Immunity Passport”. Germany is leading the way according to the Guardian “Researchers in Germany are currently preparing a mass study into how many people are already immune to the Covid-19 virus, allowing authorities to eventually issue passes to exclude workers from restrictive measures currently in place”. Other countries have to establish Immunity passports that are internationally accepted. As of today, this is an unsolved problem with many ethical and logistical implications beyond the scope of this article.
Hospitals are still under stress. Everyday new people are in critical need of ICUs, putting the maximum capacity of Italian hospitals under severe stress. As of today we have almost 4000 people fighting for life and everyday about 50–100 new people enter a similar situation.
5th indicator: As ICUs are a critical resource to fight the epidemic, it is mandatory to remain at home until ICU capacity provides a reasonable safety buffer. The hospital is one of the places most at risk, because if doctors and nurses don’t have sufficient resources (including not only personal protective equipment but also time and space) to handle the emergency safely, this could cause many invisible infections; bear in mind that doctors and nurses visit or meet hundreds of people a day.
6th indicator: It is necessary to reduce to zero the number of people who die at home, without having done or having taken the test, before they arrive in the hospital and can be treated in the best way in the hospital: this situation in Italy is happening in Lombardy, with some patients reported dead at home before arriving at the hospitals.
When the above six indicators are green, Italy can declare the end of Phase 1 and the start of Phase 2. During the whole of Phase 1, Italians have to stay at home to avoid the restart of the pandemic and new horrific waves of deaths.
Phase 2
At the end of phase 1 Italy can declare that COVID has been successfully contained with a significant cost in terms of life. However, this does not mean that the risk is over, as new positives can still travel undetected to Italy.
Unless either a cure or a vaccine is created, an international travel ban should be put in place similar to the one currently adopted in China at the end of March “China will close its borders to foreigners starting on Saturday, March 28, in a dramatic step to try to stop the coronavirus coming in from abroad.”
Only people with an internationally recognized certification of having developed antibodies after being positive will be allowed to travel internationally.
The WHO has already alerted countries about the risk of resurgence of the virus with a second wave in Asia “Coronavirus pandemic ‘far from over’ in Asia”
7th indicator: During phase 2, international borders need to be closed. A zero travel policy should be put in place. Only recovered people with an immunity passport can circulate. During this phase, continuous samples of a statistically significant part of the global population should be put in place, aiming to discover potential new COVID clusters. Sampling has to last for several months and the indicator will turn green only if zero clusters are discovered. How long is the period and how large is the sample is still an open problem.
When the above seven indicators are green, Italy can declare the end of Phase 2 and the start of Phase 3.
Phase 3
This is the phase of return to normality. As stated at the beginning, the intent of this document is to highlight the indicators that decision makers have to take into account before deciding the right moment to reopen a country post-COVID. If the right steps are not put in place there is a very high risk of either being stuck forever in a Phase 1 or entering briefly in Phase 2 and never moving to Phase 3. If the right steps are not put in place, there is a very high risk of having a second wave of contagion and hundreds of thousands of new deaths.
Conclusion
I am neither an epidemiologist nor a virologist. My work is to look at data and infer the likelihood of different scenarios.
At the end of January, 2020 my red alert was sent to friends and authorities to pay attention to COVID because the situation was extremely worrying. The alert went unheeded.
At the end of January, 2020 when I spoke with my son, Lorenzo, 19 years old, about the risk and the need of buying masks, he corrected me and suggested buying N99 masks instead of less secure N95 masks. Independently from me he reached the same conclusions. All the signals were there for anyone who wanted to listen. There was just a need for a high school background in math and an open unbiased mind.
At the end of March, 2020, this document has been written to send a second alert.
This time is to avoid a genocide.
“Let me be clear. The epidemic is far from over in Asia and the Pacific. This is going to be a long-term battle and we cannot let down our guard”, WHO, April, 1st 2020