Over the last 100 years, the U.S. has had to respond to five avian flu pandemics. The most severe was the 1918 avian influenza infecting 1/3 of the world’s population and killing 650,000 Americans. It was also the last time wide-spread containment, mitigation, and isolation strategies were used in the U.S. Seldom mentioned about the 1918 pandemic are the three “waves” or cycles of resurgence and the subsequent deaths associated with them, especially in cities and towns that failed to implement timely mitigation restrictions or rescinded them too quickly.

When considering the rescindment of mitigation restrictions, a bottom-to-top approach (local-state-federal governments) must be followed precisely to account for the kinetics of the virus. It is the virus that will truly dictate when American lives can return to some semblance of normal. The goal is to taper restrictions to avoid a cycle of new COVID-19 outbreaks and thus minimize the similar cycle of deaths, which followed in the 1918 pandemic.

The CDC recommends mitigation guidelines based on the Pandemic Severity Index (PSI), a 1-5 scale projection of U.S. deaths assuming a 30% illness rate. The 1918 Avian flu registered a PSI of 5, and so does COVID-19. Based on this, a minimum of 12 weeks of mitigation strategies is recommended. The gap between 12-week mitigation strategies and estimated vaccine availability (12-18 months) has not been addressed appropriately by government or public health officials to date; this is especially concerning in light of calls to “reopen” the country or, more accurately, the economy.

Before any state-wide “stay-at-home” order can be lifted, five primary drivers must be addressed and implemented for every county in every state.

1. Hospital preparedness/epidemic plans

During this crucial time of “flattening the curve,” hospitals (when able) must design and implement a COVID-19 epidemic plan and run the necessary exercises to drill down to the root causes of obstacles in operation. Through collaborative partnerships among stakeholders, hospital systems must secure and stockpile an 8-week supply of required personal protective equipment (PPE) and cleaning supplies for all medical and nonmedical personnel; ensure access to a surge capacity of ventilators and treatment facilities; as well as ensure all necessary therapeutics for non-COVID-19 patients are readily available. Before COVID-19, acute care hospital occupancy rates nationally for urban and rural centers were 64% and 42.7%, respectively. As such, an occupancy threshold of 80% should be established for activation of surge capacity operations while an occupancy threshold of 90% should activate the COVID-19 epidemic plan.

2. Viral testing

It’s the testing, stupid – pardon the riff on James Carville’s coined phrase, but it cannot be overstated. Before any state-wide mitigation order can be rescinded, every county must have the infrastructure in place to test anyone who wants and needs a test. County health officials must collaborate with all public and private sector stakeholders to institute a robust network of COVID-19 testing centers that will serve as access points to the health care system, inform viral spread rates, and, most importantly, identify asymptomatic COVID-19+ individuals. A major milestone in infrastructure testing security is when 4-8% of county populations are being tested daily to identify, isolate, and maintain low-transmission rates.

3. Contact tracing

According to CDC models, approximately 11 close contacts must be traced and tested for each COVID-19+ case. This level of contact tracing will require a state lead and county executed “army” corps of public health, academic, volunteer, and private sector personnel. These individuals must be trained and “deputized” to do the arduous work of manual contact tracing. Equally important is the utilization of digital tools to expand the reach and efficacy of contact tracers. Nearly 96% of Americans own a cell phone; of those, 81% own a smartphone. End-user apps, as well as smartphone technology, are being designed by tech companies to bolster contact tracing efforts. It is imperative that civil liberty and privacy concerns be addressed promptly, at the state level, in preparation for the availability of such powerful digital tools.

4. Antibody screening

In the past several weeks, the FDA has approved three serological antibody blood tests for COVID-19, with nearly 50 more tests in the pipeline vying for approval. As the virus spreads through the population, it will be important to identify individuals who have recovered from the disease, whether they had symptoms or were asymptomatic. Those who have developed an immune response have an opportunity to play a crucial role in reopening the local economy by returning to work. They may also play an important role in the survival of others by donating their antibody-rich plasma for convalescent treatments of the critically ill. It should be a priority of state and county officials to make antibody tests widely available following any lifting of mitigations.

5. Information dissemination

Amid any public health emergency, the level of public trust in state and local officials will rise and fall based on the quality of communication received. As state-wide “stay-at-home” orders are lifted, county health officials must be tapped into the pulse of the community they serve. This communication should utilize multiple platforms, including television, radio, postal mail, newspapers, community newsletters, internet, social media, and cell phones. County officials must make their presence and authority known to the local public through the dissemination of facts; efforts should be made to lessen the relative uncertainty that comes with evolving public health information. Communication challenges throughout a pandemic will undoubtedly vary; nonetheless, the message must be consistent, regular, clear, empathetic, compassionate, and, most importantly, trustworthy. There is a strong likely-hood that community and regional mitigation restrictions will be reinstituted should a subsequent COVID-19 epidemic emerge. By establishing credibility ahead of time, county governments can increase the viability of future mitigation efforts.

At the county level, this comprehensive set of 5 mitigation drivers should be implemented and calibrated to capacity and within context, to slow down transmission and reduce mortality associated with COVID-19, with the ultimate goal of reaching and/or maintaining a steady state of low-level or no transmission.

Nicolas K. Fletcher is a medical student.

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