COVID-19: One Step Ahead

April 03, 2020|3:42 p.m.| Marcus Plescia MD, MPH | ASTHO Chief Medical Officer

As we brace ourselves for large numbers of seriously ill COVID-19 patients to test the capacity of our healthcare system, we must not lose sight of the primary role that public health departments play in responding to any outbreak: preventing community-wide transmission of disease. The news is full of stories of personal protective equipment and ventilator shortages, and while those are certainly urgent needs in states and territories today, public health departments must continue taking action to mitigate and ultimately contain this epidemic by motivating widespread public participation in physical distancing and building capacity to contain the virus in the foreseeable future. Public health leaders can accomplish this by enacting the behavior change strategies, surveillance, and disease control practices that are—and have always been—at the core of the agency’s mission and expertise.

Make the Healthy Choice the Easy Choice
Behavior change is an important intervention across the public health spectrum and the evidence-base for this approach has evolved considerably. The adage of ‘making the healthy choice the easy choice’ also applies to physical distancing. Just as we have done in injury prevention, physical activity, and tobacco control, we should use policy and environmental change to address access issues and shape norms to increase public adherence to physical distancing behaviors. This will require creativity, as physical distancing is not a behavior we have previously encouraged.

Policy and regulatory approaches to increasing public participation in physical distancing have been widespread, as states and local communities have closed schools, shut down restaurants and bars, limited gatherings, and issued “stay at home” and shelter-in-place orders. As states continue to adopt these approaches, our efforts must shift to increasing public adherence through environmental changes and communication campaigns. Environmental changes can be restrictive (e.g. removing basketball hoops in parks) or permissive (e.g. opening city streets up to foot traffic to provide more space for recreation). We must rapidly implement and experiment with a wide range of policies, actions, and modifications to remove barriers to intervention. Communication campaigns must reinforce these new behaviors and focus on creating new social norms. Past implementation of interventions, such as smoking bans and seat belt use, have relied predominantly on physical enforcement to further adherence, and a similar approach may be taken to increase the public’s commitment to physical distancing practices.

Preparing to "Return to Normal"
Documents from American Enterprise Institute and Resolve to Save Lives provide guidance as to how we can manage the COVID-19 epidemic once we advance past the imminent peak in severe cases. Until we develop a vaccine or viable treatment strategy, ongoing testing, isolation, monitoring, and contact tracing will be a necessary to contain the epidemic and prevent another spike. As it is not clear whether the current state and local health department workforce capacity is sufficient for managing this task, we must immediately prepare to meet these anticipated needs. Expanded epidemiology and infection control expertise workforce can be recruited from academia, medical care, or the non-profit sector. Florida recently announced plans to contract for 100 epidemiologists from universities across the state. Existing staff can be retrained and displaced workers (e.g. peace corps volunteers) could be hired and trained for select tasks. These creative approaches are rapidly emerging, but require immediate contracting, recruitment, and retraining.

A second approach to increasing public health capacity is to expand the use of technology. The text-based illness monitoring system, developed by CDC, is just one in a wide range of tracking systems that state and local health departments are using to facilitate self-monitoring and reporting by at-risk or quarantined individuals. Tablet and cell phone technology could also expand capacity to monitor vital signs like fever. More assertive electronic monitoring of individual movement has been used successfully to control COVID-19 in other countries. While some of these approaches raise privacy issues, the public may be more accepting given the extraordinary circumstances associated with this epidemic and a desire to get society back to "normal." Approaches such as these could substantially expand state and local health department capacity to monitor patients with COVID-19, as well as their contacts. States, national associations, and the federal government should pursue public/private partnerships that could help bring disease control technology into rapid use while balancing the need for privacy and confidentiality.

As we work to "flatten the curve" of this epidemic, we must also be one step ahead of it. The greatest challenge to being proactive is the tyranny of the many urgent needs that plague us. Public health leaders can continue to support proven outbreak response efforts, while also seeking out new ways to innovate on the interventions that will ultimately control this epidemic—and we must do so now.