Exiting lock-down: a multi-step, localized, Greece-based proposal
Georgios Pappas, Dimitrios Matthaiou, Georgios Kargiolakis, Nikolaos Papachristou
The novel coronavirus SARS-CoV-2 is currently exerting major mortality toll, significant health systems’ disruption, and unprecedented, for the modern world, socioeconomic consequences (1,2), particularly in certain Western European countries (3), resulting in the need for extensive mitigation measures for a prolonged period.
Since the universal lock-down is an unprecedented situation, and there are no blueprints for exiting from it, (not only for SARS-CoV-2 but for similar epidemic situations in general) (4), authorities in national and international level need to design an exit strategy with a feasible return to normality. They need to do this by ensuring that there will be no recurring epidemic flares in conjunction with alleviating the ensuing universal economic recession. Such exit plans have to take into account each individual country’s parameters, such as the severity of the epidemic, the financing toll and the burden of its healthcare system due to the epidemic, as well as economic, sociopolitical and geographical characteristics. Nevertheless, as the nature of the lock-down measures and the pandemic dynamics are common for all countries, certain exit strategies, tailored to each country’s needs and characteristics, could be applied to most if not all of them.
The SARS-CoV-2 epidemic reached Greece in the end of February, imported, as for many European countries, from Northern Italy. The day following the diagnosis of the 1st case, the government decided to cancel all carnival festivities. As more imported cases were recorded, followed by cases of native transmission and cases of unknown epidemiological exposure, the national authorities subsequently proceeded to gradually stricter measures (even defying the opinion of the highly influential Greek orthodox Church). Notably enough, the SARS-CoV-2 epidemic in Greece has not evolved so far as dramatically as in numerous other European countries. As of April 25th, 2020, 2490 cases have been diagnosed, 130 deaths have been recorded, and only 48 patients have been at the moment admitted in Intensive Care Units (ICU): moreover, the number of patients admitted to the ICU has been constantly decreasing for all the past week, refers to only a fourth of all the ICU beds initially designated for patients with COVID-19 (i.e. coronavirus disease), and roughly 6% of the national ICU bed capacity (official data from https://eody.gov.gr/neos-koronaios-covid-19/). Putting these numbers into context, Greece exhibits one of the lowest European numbers in terms of deaths per million of population.
Interestingly enough, this epidemic seems to have spared several areas of Greece. The country of Greece possesses some unique geographical characteristics, with more than 6000 islands of which 117 are inhabited, and extensive mountainous areas that effectively isolate whole regions (forms of topographic isolation can be observed in numerous other countries, typical examples being the Italian islands, the Spanish autonomous communities, the Swiss cantons, the UK ceremonial counties, or the US and Germans states). Greece is administratively divided into 13 regions and 74 regional units, although the latter are often substituted in statistic studies by the pre-existing prefectures.
As of April 25, at least 3 prefectures had not recorded any SARS-CoV-2 cases. Almost 20 more prefectures have exhibited low viral prevalence (<5 cases per 100.000 inhabitants). In some of these low-prevalence prefectures, for example Thesprotia in the region of Epirus in Northwestern Greece, the single case who has been recorded had not even visited the region (i.e. these cases returned from abroad and were diagnosed and quarantined in Athens). Furthermore, in other prefectures no new indigenous cases have been recorded, for more than two weeks after their initial cases. Thus, these negative, for reported cases, prefectures, along with the low-prevalent but recently silent prefectures can be safely considered as free of communal viral circulation.
Since the extended quarantine measures exert major psycho-social consequences (5), particularly when protracted, and since the economic burden of lock-down is massive, states have to develop plans for a smooth return to normal life, through gradual loosening of the social distancing/ cordon sanitaire measures. At present, these measures have been extended until May 4th, including the week preceding and following the Greek Orthodox Easter (April 19) too. During this period mass movements from metropolitan centers to rural areas would have been expected to occur. Most interactions between prefectures are limited, as movement is practically restricted to essential personnel, brief leisure activities near one’s residence, or provision of assistance services to the elderly and the incapacitated. It is important to highlight here, that someone can presume, that certain prefectures could be practically sealed from entrance of new residents if needed as the geographic landscape of Greece allows such isolation planning. A typical case is Greek islands where access to is currently prohibited, with the exception of the permanent residents’ commute for urgent reasons.
Currently, there are no- publicly known- plans to lift lock-down restrictions in Greece. Taking into consideration the current evidence for the three sub-components (i.e, evolution of the disease over time; transmission of the illness among inhabitants of the same province; the effects of spatial neighborhood and the effects of nearby areas) that characterize the initial spatial-temporal transmission and outbreak of the SARS-CoV-2 (6), we present, here, a comprehensive initial plan of the gradual regional lock-down lifting. This strategy could potentially be applied to other countries as well, adjusted to their individual geographical and epidemiological characteristics.
An exit strategy
Knowing that the determinants of the epidemic are agent-related, host-related or environment-related, it is important to implement a strategy aiming at the modification of these determinants where applicable. Agent-related and environmental-related determinants are inherent characteristics of the disease and represent constant values. As such, they cannot be modified. On the other hand, host-related determinants can be largely modifiable. In this scenario, most of the interventions should be focused on the social organization characteristics and especially on retaining the relatively high segregation, surveying “high-risk” populations and groups with increased social contact, either mandatory or optional.
Starting at May 4th, we propose the gradual loosening of restrictions at the prefectures that have zero cases (assuming that they will continue having zero cases the following days). This gradual lock-down lifting could be attempted in parallel at certain low-prevalent and currently “silent” prefectures (assuming that they will continue to be silent until May 4th). May 4th has been presumably chosen as the current restriction deadline from the state, in order to minimize the effect of May 1st, a date when mass outdoor activities (in joint with the subsequent weekend of May 2nd and May 3rd) but also mass gatherings honoring the International Workers’ Day are expected (although the government reported that these gatherings were transferred to May 9th!). On May the 4th, people in these prefectures will be allowed to exit their residences freely, while an aggressive campaign suggesting to the elderly and the susceptible populations that they should nevertheless stay at home, will have taken place in the preceding days. Furthermore, certain popular places that typically gather numerous citizens for leisure (i.e. parks, beaches, seasonal touristic resorts) should remain closed to the public. A maximal number of people for any kind of outdoor gathering should be set, preferably at 10. All retail stores will open, with the limitations for the presence of simultaneous customers according to each store’s area, and the compulsory use of a face mask when inside. Schools should not open: although there has been extensive debate in the scientific literature about the utility of schools’ closure in containing the current epidemic (7), the satisfactory introduction of e-learning during the quarantine period and the relatively short duration of the remaining school season (6 weeks), allows for continuing closure of the educational facilities. Regarding higher education, e-learning can be an adequate alternative for most universities, ensuring that student movements between their birthplace and their University base will be avoided. Places where the elderly coalesce should also remain closed, including religious temples of all denominations. Coffee shops and restaurants will open but only on a take-away basis (at least until the weather allows for sparsely placed outdoor seats and tables). All kinds of group sports activities should remain prohibited, including professional sports activities and events.
Some hotels will also open in a varying capacity, adjusted to individual prefecture needs (certain hotels for example host personnel of non-governmental-organizations working in the area, or even refugees). Depending on the percentage of healthcare workers that have contracted SARS-CoV-2 and have developed immunity, it might be feasible to develop a healthcare task force composed by such individuals: these individuals would not have the burden of extreme precautions, and would not be any further potential disease spreaders. Such a registry could be developed for other essential workers as well. Access restriction to nursing homes, refugee centers, and all similar facilities should remain, as with other structures of compartmentalized population.
It is important to mention here that the major limitation related to the success of this gradual lock-down lifting, is to minimize the entry into the newly open prefectures. As already mentioned, the Greek geography allows for a relatively feasible implementation of this: islands cannot be accessed freely- many prefectures have essentially 2 to 5 major entrances that can be safeguarded, allowing for reasonable and safe movement of specific professionals and basic trade goods; the latter can be pre-approved through a prefecture/state call center. Commercial air travel should preferably be avoided in this initial phase. Intra-prefecture travel on the other hand should be allowed, with particular precautions taken for public transport hubs (i.e. bus, train and ship stations, taxi stands) but also for the number of passengers allowed in any ride.
Surveillance prerequisites
In parallel with these, the state should apply some basic complementary measures to monitor and assess timely and effectively how the gradual re-opening is performing (8). Each prefecture needs a centralized diagnostic laboratory that can perform tens (or even hundreds) of molecular diagnostic tests in a daily manner. Such duties could be performed by existing local or neighboring hospital or university facilities. General practitioners should refer for testing any patient with symptoms potentially attributable to SARS-CoV-2, while random sampling of asymptomatic individuals should also be performed. Finally, in touristic places with a fairly isolated geography but sufficient capacity (i.e. large islands), the development of screening and monitoring infrastructures, where are non-existent, could be augmented by local authorities and professional entities related to tourism.
The establishment of this network of measures and activities could create the capacity for a specially trained and assigned team of epidemiologists to immediately track contacts of any new case, and, depending on the epidemiological characteristics of such a case, re-institute lock-down immediately. If no new cases are recorded during the following 14–20 days (i.e. reaching May 18, or May 24), it would be reasonable to consider the merging of the neighboring prefectures that have successfully opened, and loosen further some of the applied restrictions. These additional steps of course are dependent on the acquired hitherto scientific knowledge regarding rapid diagnosis, therapeutic options and the sufficient supply and existence of any prophylactic pharmaceutical regimens. During this time period, it would be useful to make the necessary capacity building preparations for other prefectures that have become silent, and thus ready for gradual opening (although applying this practice to a metropolitan center like Athens would probably need more days, closer monitoring and more resources).
Through this gradual re-opening we hope that we can prematurely ameliorate part of the huge economic burden in local societies where SARS-CoV-2 has entered minimally. Most importantly, we become wiser for this unprecedented process with minimal risk: the current pandemic necessitates that we act in parallel with learning (i.e. in terms of viral biology, epidemiology, pharmacology, sociology, and politics). While in controlling the epidemic centralized decisions seem to be more effective6, our de-escalation strategy allows for any mistake to have localized impact, and thus be prevented when a lock-down lifting is attempted in a larger area/ population.
Special focus on tourism
Although restoring those parts of society that are most crucial and least vulnerable is a top priority, tourism is considered a major component of the Greek economy . Since certain of the currently silent prefectures are popular tourist destinations throughout the year, preparedness for a subsequent period should also be initiated: for example, restrictions regarding domestic travel and, later, international travel to other countries performing equally well in containing the virus could also be lifted, depending, and thoroughly following, global SARS-CoV-2 epidemiology. Such a preparedness plan should definitely focus on methods of strict and strategic monitoring of all travellers upon arrival and during their stay, restrictions regarding flights and hotels’ occupancy, as well as availability of sanitizers, face masks and other hygiene materials. Areas that could allow visitors from other countries could be large islands, such as Crete, Euboea and Rhodes, islands that are close to metropolitan areas and other parts of Greece that could support lock-down lifting (e.g. Mani in Peloponnese, Chalkidiki close to Thessaloniki). Inbound flights could be restricted to a couple of airports, such as Athens El. Venizelos and Crete’s main hub in Heraclion to allow proper monitoring and wise resource management. A major consideration is cruise ships and other ships traveling to the islands. Our opinion is that cruise ships should not be allowed to dock and ships traveling to Greek islands will be allowed only under strict restrictions. Finally, flights should be preferred from sea travel, as risk is reduced (less time consuming, easier to control and impose restrictions).
Challenges and implications
Unfortunately, epidemics caused by pathogens with such significant transmissibility are hard to contain and easy to relapse. For example, isolated neglects of duty or even unfortunate events may derange the epidemic curve and cause flares of new cases and community transmission. The aforementioned risks become particularly significant in closed facilities and populations where these flares may disproportionately multiply (i.e.refugee centers or Roma communities). In order to minimize the risk of such flares, the state should enhance surveillance and detection practices in these communities. Not to be disregarded, a further risk may be present in eastern prefectures accessible to refugee waves, especially since the epidemic in Turkey has rapidly expanded: if such prefectures are opened, appropriate facilities for quarantine of any new refugees should be prepared, taking into account both public health and human rights principles.
The present strategy has its own merit of limitations. It does not take into account the possibility of a second epidemic wave as we cannot predict viral behavior during the warmer summer months. It also overlooks the potential damage created by super-spreaders, since there are no reliable detection means of such individuals at present, beyond thorough contact tracking and composite epidemiology. Furthermore, it may entail the risk of political tensions since opening specific prefectures while keeping restrictions in others may not seem prudent or preferable to different parties.
Nevertheless, even with a partial success in the opening of certain prefectures, the political and scientific authorities will become experienced and skilled enough about the process and will be able to lift the social burden of the disease for a considerable amount of the population (who would otherwise have to patiently wait for more densely-populated cities to achieve a level of viral silence). Hopefully, this approach can be augmented in the future months by the potential availability of reliable preventive and therapeutic regimens, or the wide availability of rapid diagnostic tests that can easily be performed beyond a centralized diagnostic laboratory. Finally, we believe that this is a plan that could possibly be implemented worldwide, adjusted to each individual country’s geography (i.e. a US state, or a Swiss canton). Furthermore, in a later phase a similar practice might be applied to international transport liaisons with other SARS-CoV-2 “silent” countries or international regions, particularly for borderline regions.
Disclaimer: The opinions expressed are those of the authors and do not necessarily represent the opinion of their employers or any professional organizations of which the authors are members.
Funding statement: No funding has been received or is pending, related to the subject and preparation of, the manuscript
Declaration and conflict of interest: None for any of the authors
Affiliations:
GP and GK: Institute of Continuing Medical Education of Ioannina, Greece, DM: Department of Critical Care Medicine, “Attikon” University Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece, and NP: University College London
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