Public health mitigation of COVID-19

This article is about public health management of COVID-19. For medical management of COVID-19, see Management of COVID-19.

Further information: Flatten the curve

Speed and scale are key to mitigation of COVID-19, due to the fat-tailed nature of pandemic risk and the exponential growth of COVID-19 infections.[1] For mitigation to be effective, (a) chains of transmission must be broken as quickly as possible through screening and containment, (b) health care must be available to provide for the needs of those infected, and (c) contingencies must be in place to allow for effective rollout of (a) and (b).[[

Part of managing an infectious disease outbreak is trying to delay and decrease the epidemic peak, known as flattening the epidemic curve.[2] This decreases the risk of health services being overwhelmed and provides more time for vaccines and treatments to be developed.[2] Non-pharmaceutical interventions that may manage the outbreak include personal preventive measures such as hand hygiene, wearing face masks, and self-quarantine; community measures aimed at physical distancing such as closing schools and cancelling mass gathering events; community engagement to encourage acceptance and participation in such interventions; as well as environmental measures such surface cleaning.[3] It has also been suggested that improving ventilation and managing exposure duration can reduce transmission.[4][5]

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## Contents

* 1 Initial containment measures
* 2 Costs and challenges
* 3 Efficacy
* 4 Contact tracing
* 4.1 Information technology
* 5 Health care
* 6 Research and development
* 7 See also
* 8 References

## Initial containment measures[edit | edit source]

Further information: Zero-COVID and Flattening the curve

Goals of mitigation include delaying and reducing peak burden on healthcare (flattening the curve) and lessening overall cases and health impact.[2][6] Moreover, progressively greater increases in healthcare capacity (raising the line) such as by increasing bed count, personnel, and equipment, help to meet increased demand.[7]

Mitigation attempts that are inadequate in strictness or duration—such as premature relaxation of distancing rules or stay-at-home orders—can allow a resurgence after the initial surge and mitigation.[2][8]

More drastic actions aimed at containing the outbreak were taken in China once the severity of the outbreak became apparent, such as quarantining entire cities and imposing strict travel bans.[9] Other countries also adopted a variety of measures aimed at limiting the spread of the virus. South Korea introduced the mass screening and localised quarantines and issued alerts on the movements of infected individuals. Singapore provided financial support for those infected who quarantined themselves and imposed large fines for those who failed to do so. Taiwan increased face mask production and penalised hoarding of medical supplies.[10] The zero-COVID approach aims to prevent viral transmission, using a number of different measures, including vaccination and non-pharmaceutical interventions such as contact-tracing and quarantine. Different combinations of measures are used during the initial containment phase, when the virus is first eliminated from a region, and the sustained containment phase, when the goal is to prevent reestablishment of viral transmission within the community.[11] Experts differentiate between zero-COVID, which is an elimination strategy, and mitigation strategies that attempt to lessen the effects of the virus on society, but which still tolerate some level of transmission within the community.[12][13] These initial strategies can be pursued sequentially or simultaneously during the acquired immunity phase through natural and vaccine-induced immunity.[14]

## Costs and challenges[edit | edit source]

Simulations for Great Britain and the United States show that mitigation (slowing but not stopping epidemic spread) and suppression (reversing epidemic growth) have major challenges. Optimal mitigation policies might reduce peak healthcare demand by two-thirds and deaths by half, but still result in hundreds of thousands of deaths and overwhelmed health systems. Suppression can be preferred but needs to be maintained for as long as the virus is circulating in the human population (or until a vaccine becomes available), as transmission otherwise quickly rebounds when measures are relaxed. Until now, the evidence for public health (nonpharmaceutical) interventions such as social distancing, school closure, and case isolation comes mainly from epidemiological compartmental models and, in particular, agent-based models (ABMs).[15] Such models have been criticized for being based on simplifying and unrealistic assumptions.[16][17] Still, they can be useful in informing decisions regarding mitigation and suppression measures in cases when ABMs are accurately calibrated.[18] An Argentinian modelling study asserted that complete lockdowns and healthcare system overextension could be avoided if 45 percent of asymptomatic patients were detected and isolated.[19] Long-term intervention to suppress the pandemic has considerable social and economic costs.[20]

## Efficacy[edit | edit source]

In August 2020, a working paper by the National Bureau of Economic Research (NBER) questioned major effects of many mitigation and suppression measures. The authors compared the development of casualties connected to SARS-CoV-2 until July 2020, in 25 US states and 23 countries that had counted more than 1.000 overall deaths each. From the date a state passed a threshold of 25 deaths, the statistical study observed a largely uniform development, independently from type and time frame of governmental interactions. Thus, the growth rate of casualties dropped to zero within 20–30 days, and the variability between regions was low, except at the beginning of the epidemics. The authors computed the effective reproduction number Reff with the aid of different models like the SIR model, and found it hovering around one everywhere after the first 30 days of the epidemic. Hence, they did not find evidence for an influence of lockdowns, travel restrictions or quarantines on virus transmission.[21] For contradicting studies, they assume an omitted variable bias. Candidates for ignored effects could be voluntary social distancing, the structure of social interaction networks (some people contact more networks faster than others), and a natural tendency of an epidemics to spread quickly at first and slow down, which has been observed in former Influenza pandemics, but not yet completely understood. The reviewer Stephen C. Miller concludes “that human interaction does not conform to simple epidemiological models”.[22][21]

Many reviews find high efficacy of mitigation measures such as vaccines, face masks and social distancing. For instance, a systematic review and meta-analysis found that mask-wearing cuts the incidence of COVID-19 by 53% overall.[23][24] The efficacy may also be substantially higher, especially if certain types of masks are worn or under specific conditions and settings.

## Contact tracing[edit | edit source]

See also: Management of COVID-19 § Information technology, and Government by algorithm

Manual contact tracing via mandatory traveler health forms at New York City's LaGuardia Airport in August 2020.

The contact tracing app "Corona-Warn-App"

Contact tracing is an important method for health authorities to determine the source of infection and to prevent further transmission.[25] The use of location data from mobile phones by governments for this purpose has prompted privacy concerns, with Amnesty International and more than a hundred other organisations issuing a statement calling for limits on this kind of surveillance.[26]

An unincentivized and always entirely voluntary use of such digital contact tracing apps by the public was found to be low[27][28][29] even if the apps are built to preserve privacy (which may however compete with alternative domestic apps that don't do so and can't always be used), leading to low usefulness of the software for pandemic mitigation as of April 2021. A lack of possible features, prevalent errors and possibly other issues reduced their usefulness further.[30] Use of such an app in general or during specific times is in many or all cases not provable or requirable.

Moreover, contact-tracing apps may be designed criteria (<1 metre; and > 15 minutes contact) insufficient for controlling danger.[31]

### Information technology[edit | edit source]

Further information: Use and development of software for COVID-19 pandemic mitigation

Several mobile apps have been implemented or proposed for voluntary use, and as of 7 April 2020 more than a dozen expert groups were working on privacy-friendly solutions such as using Bluetooth to log a user's proximity to other cellphones.[26] (Users are alerted if they have been near someone who subsequently tests positive.)[26]

On 10 April 2020, Google and Apple jointly announced an initiative for privacy-preserving contact tracing based on Bluetooth technology and cryptography.[32][33] The system is intended to allow governments to create official privacy-preserving coronavirus tracking apps, with the eventual goal of integration of this functionality directly into the iOS and Android mobile platforms.[34] In Europe and in the U.S., Palantir Technologies is also providing COVID-19 tracking services.[35]

In February 2020, China launched a mobile app to deal with the disease outbreak.[36] Users are asked to enter their name and ID number. The app can detect 'close contact' using surveillance data and therefore a potential risk of infection. Every user can also check the status of three other users. If a potential risk is detected, the app not only recommends self-quarantine, it also alerts local health officials.[37]

Big data analytics on cellphone data, facial recognition technology, mobile phone tracking, and artificial intelligence are used to track infected people and people whom they contacted in South Korea, Taiwan, and Singapore.[38][39] In March 2020, the Israeli government enabled security agencies to track mobile phone data of people supposed to have coronavirus. According to the Israeli government, the measure was taken to enforce quarantine and protect those who may come into contact with infected citizens. The Association for Civil Rights in Israel, however, said the move was "a dangerous precedent and a slippery slope".[40] Also in March 2020, Deutsche Telekom shared aggregated phone location data with the German federal government agency, Robert Koch Institute, to research and prevent the spread of the virus.[41] Russia deployed facial recognition technology to detect quarantine breakers.[42] Italian regional health commissioner Giulio Gallera said he has been informed by mobile phone operators that "40% of people are continuing to move around anyway".[43] The German Government conducted a 48-hour weekend hackathon, which had more than 42,000 participants.[44][45] Three million people in the UK used an app developed by King's College London and Zoe to track people with COVID‑19 symptoms.[46][47] The president of Estonia, Kersti Kaljulaid, made a global call for creative solutions against the spread of coronavirus.[48]

## Health care[edit | edit source]

Further information: Flattening the curve, List of countries by hospital beds, and Shortages related to the COVID-19 pandemic

An army-constructed field hospital outside Östra sjukhuset (Eastern hospital) in Gothenburg, Sweden, contains temporary intensive care units for COVID-19 patients.

Increasing capacity and adapting healthcare for the needs of COVID-19 patients is described by the WHO as a fundamental outbreak response measure.[49] The ECDC and the European regional office of the WHO have issued guidelines for hospitals and primary healthcare services for shifting of resources at multiple levels, including focusing laboratory services towards COVID-19 testing, cancelling elective procedures whenever possible, separating and isolating COVID-19 positive patients, and increasing intensive care capabilities by training personnel and increasing the number of available ventilators and beds.[49][50] In addition, in an attempt to maintain physical distancing, and to protect both patients and clinicians, in some areas non-emergency healthcare services are being provided virtually.[51][52][53]

## Research and development[edit | edit source]

There are research-based developments that aim to mitigate COVID-19 spread beyond vaccines, repurposed and new medications and similar conventional measures.

Researchers investigate for safe ways of public transport during the COVID-19 pandemic.[54][55]

Novel vaccine passports have been developed.

Researchers are developing face-masks which could be more effective at reducing SARS-CoV-2 spread than existing ones and/or have other desired properties such as biodegradability and better breathability.[56][57][58][59][60][61] Some are also researching attachments to existing face-masks to make them more effective[60] or to add self-cleaning features.[60] The pandemic has increased efforts to develop such masks and some have received government grants for their development.[60]

Ventilation and air cleaners are also the subject of research and development.[62][63]

Researchers report the development of chewing gums that could mitigate COVID-19 spread. The ingredients – CTB-ACE2 proteins grown via plants – bind to the virus.[64][65]

On 23 April 2020, NASA reported building, in 37 days, a ventilator (called VITAL).[66][67] On April 30, NASA reported receiving fast-track approval for emergency use by the United States Food and Drug Administration for the new ventilator.[68] As of March 2020[update], 26 manufacturers around the world have been licensed to make the device.[69] The COVID-19 pandemic increased the demand for oxygen concentrators. During the pandemic open source oxygen concentrators were developed, locally manufactured – with prices below imported products – and used, especially during a COVID-19 pandemic wave in India.[70][71] Due to capacity limitations in the standard supply chains, some manufacturers are 3D printing healthcare material such as nasal swabs and ventilator parts.[72][73] In one example, when an Italian hospital urgently required a ventilator valve, and the supplier was unable to deliver in the timescale required, a local startup received legal threats due to alleged patent infringement after reverse-engineering and printing the required hundred valves overnight.[74][75][76]

## See also[edit | edit source]

* Treatment and management of COVID-19#Prevention of onward transmission
* Impact of the COVID-19 pandemic on science and technology

## References[edit | edit source]

1. ↑ Cirillo, Pasquale and Nassim Nicholas Taleb (2020). "Tail Risk of Contagious Diseases". Nature Physics. 16 (6): 606–613. arXiv:2004.08658. Bibcode:2020NatPh..16..606C. doi:10.1038/s41567-020-0921-x. S2CID 215828381.
2. ↑ 2.0 2.1 2.2 2.3 Anderson RM, Heesterbeek H, Klinkenberg D, Hollingsworth TD (March 2020). "How will country-based mitigation measures influence the course of the COVID-19 epidemic?". Lancet. 395 (10228): 931–934. doi:10.1016/S0140-6736(20)30567-5. PMC 7158572. PMID 32164834. "A key issue for epidemiologists is helping policy makers decide the main objectives of mitigation—e.g. minimising morbidity and associated mortality, avoiding an epidemic peak that overwhelms health-care services, keeping the effects on the economy within manageable levels, and flattening the epidemic curve to wait for vaccine development and manufacture on scale and antiviral drug therapies."
3. ↑ "Community Mitigation Guidelines to Prevent Pandemic Influenza—United States, 2017". Recommendations and Reports. 66 (1). 2017-04-12. Archived from the original on 2020-05-03. Retrieved 2022-03-06.
4. ↑ Epperly, David E.; Rinehart, Kristopher R.; Caney, David N. (2020). "COVID-19 Aerosolized Viral Loads, Environment, Ventilation, Masks, Exposure Time, Severity, And Immune Response: A Pragmatic Guide Of Estimates". medRxIv. doi:10.1101/2020.10.03.20206110. Archived from the original on 2021-08-29. Retrieved 2022-03-06.
5. ↑ "Viral Load Exposure Factors". ReallyCorrect.com. Archived from the original on 2021-05-06. Retrieved 2022-03-06.
6. ↑ Qualls N, Levitt A, Kanade N, Wright-Jegede N, Dopson S, Biggerstaff M, et al. (April 2017). "Community Mitigation Guidelines to Prevent Pandemic Influenza - United States, 2017". MMWR. Recommendations and Reports. 66 (1): 1–34. doi:10.15585/mmwr.rr6601a1. PMC 5837128. PMID 28426646.
7. ↑ Barclay E, Scott D, Animashaun C (2020-04-07). "The US doesn't just need to flatten the curve. It needs to "raise the line."". Vox. Archived from the original on 2020-04-07.
8. ↑ Wiles S (2020-03-14). "After 'Flatten the Curve', we must now 'Stop the Spread'. Here's what that means". The Spinoff. Archived from the original on 2020-03-26. Retrieved 2020-03-13.
9. ↑ Qin, Amy (2020-03-07). "China May Be Beating the Coronavirus, at a Painful Cost". The New York Times. Archived from the original on 2020-05-15. Retrieved 2022-03-06.
10. ↑ McCurry J, Ratcliffe R, Davidson H (2020-03-11). "Mass testing, alerts and big fines: the strategies used in Asia to slow coronavirus". The Guardian. Archived from the original on 2020-04-11. Retrieved 2022-03-06.
11. ↑ Anna Llupià, Rodríguez-Giralt, Anna Fité, Lola Álamo, Laura de la Torre, Ana Redondo, Mar Callau and Caterina Guinovart (2020) What Is a Zero-COVID Strategy Archived 2022-01-03 at the Wayback Machine, Barcelona Institute for Global Health - COVID-19 & response strategy.
12. ↑ Oliu-Barton, Miquel; Pradelski, Bary S R; Aghion, Philippe; Artus, Patrick; Kickbusch, Ilona; Lazarus, Jeffrey V; Sridhar, Devi; Vanderslott, Samantha (28 April 2021). "SARS-CoV-2 elimination, not mitigation, creates best outcomes for health, the economy, and civil liberties". The Lancet. 397 (10291): 2234–2236. doi:10.1016/S0140-6736(21)00978-8. PMC 8081398. PMID 33932328.
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14. ↑ Bhopal, Raj S (9 September 2020). "To achieve "zero covid" we need to include the controlled, careful acquisition of population (herd) immunity". BMJ. 370: m3487. doi:10.1136/bmj.m3487. eISSN 1756-1833. PMID 32907816. S2CID 221538577.
15. ↑ Adam D (April 2020). "Special report: The simulations driving the world's response to COVID-19". Nature. 580 (7803): 316–318. Bibcode:2020Natur.580..316A. doi:10.1038/d41586-020-01003-6. PMID 32242115. S2CID 214771531.
16. ↑ Squazzoni F, Polhill JG, Edmonds B, Ahrweiler P, Antosz P, Scholz G, et al. (2020). "Computational Models That Matter During a Global Pandemic Outbreak: A Call to Action". Journal of Artificial Societies and Social Simulation. 23 (2): 10. doi:10.18564/jasss.4298. ISSN 1460-7425. S2CID 216426533. Archived from the original on 2021-02-24. Retrieved 2022-03-06.
17. ↑ Sridhar D, Majumder MS (April 2020). "Modelling the pandemic". BMJ. 369: m1567. doi:10.1136/bmj.m1567. PMID 32317328. S2CID 216074714. Archived from the original on 2021-05-16. Retrieved 2022-03-06.
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19. ↑ Mayorga L, García Samartino C, Flores G, Masuelli S, Sánchez MV, Mayorga LS, Sánchez CG. "A modelling study highlights the power of detecting and isolating asymptomatic or very mildly affected individuals for COVID-19 epidemic management." BMC Public Health. 2020 Nov 27;20(1):1809. doi: 10.1186/s12889-020-09843-7. PMID: 33246432 Archived 2021-08-02 at the Wayback Machine Retrieved 14 January 2021.
20. ↑ "Impact of non-pharmaceutical interventions (NPIs) to reduce COVID19 mortality and healthcare demand" (PDF). Imperial College COVID-19 Response Team. 2020-03-16. Archived (PDF) from the original on 2020-03-16. Retrieved 2022-03-06.
21. ↑ 21.0 21.1 Stephen C. Miller (2020-08-26). American Institute for Economic Research (ed.). "Lockdowns and Mask Mandates Do Not Lead to Reduced COVID Transmission Rates or Deaths, New Study Suggests". Archived from the original on 2020-09-12. Retrieved 2020-09-11. With link to the complete NBER Working Paper Archived 2021-04-22 at the Wayback Machine, August 2020, there Figure 2, p. 18.
22. ↑ Andrew Atkeson, Karen Kopecky und Tao Zha: Four stylized facts about Covid-19 Archived 2021-04-22 at the Wayback Machine. NBER Working Paper, August 2020, Introduction p. 2–4, Conclusion p. 15–16. Retrieved 2020-09-12.
23. ↑ "Mask-wearing cuts Covid incidence by 53%, says global study". The Guardian. 18 November 2021. Archived from the original on 18 November 2021. Retrieved 18 November 2021.
24. ↑ Talic, Stella; Shah, Shivangi; Wild, Holly; Gasevic, Danijela; Maharaj, Ashika; Ademi, Zanfina; Li, Xue; Xu, Wei; Mesa-Eguiagaray, Ines; Rostron, Jasmin; Theodoratou, Evropi; Zhang, Xiaomeng; Motee, Ashmika; Liew, Danny; Ilic, Dragan (18 November 2021). "Effectiveness of public health measures in reducing the incidence of covid-19, SARS-CoV-2 transmission, and covid-19 mortality: systematic review and meta-analysis". BMJ. 375: e068302. doi:10.1136/bmj-2021-068302 (inactive 28 February 2022). ISSN 1756-1833. PMID 34789505.`{{cite journal}}`: CS1 maint: DOI inactive as of February 2022 (link)
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27. ↑ "Too few Germans using coronavirus pandemic tracing app | DW | 17.09.2020". Deutsche Welle. Archived from the original on 10 April 2021. Retrieved 8 April 2021.
28. ↑ "Vaccine passport apps are here. But the technical challenges are still coming". The Seattle Times. Archived from the original on 9 April 2021. Retrieved 8 April 2021.
29. ↑ "96% of Canadians who test positive for coronavirus aren't using COVID Alert app properly". Global News. Archived from the original on 10 April 2021. Retrieved 8 April 2021.
30. ↑ "Corona-Warn-App 2.0: Check-in per QR-Code startet nach Ostern". t3n Magazin (in Deutsch). Archived from the original on 7 April 2021. Retrieved 8 April 2021.
31. ↑ Rowe, Frantz; Ngwenyama, Ojelanki; Richet, Jean-Loup (2 September 2020). "Contact-tracing apps and alienation in the age of COVID-19". European Journal of Information Systems. 29 (5): 545–562. doi:10.1080/0960085X.2020.1803155. ISSN 0960-085X. S2CID 224891520.
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34. ↑ "Apple and Google partner on COVID-19 contact tracing technology". 2020-04-10. Archived from the original on 2020-05-20. Retrieved 2020-04-10.
35. ↑ "Palantir provides COVID-19 tracking software to CDC and NHS, pitches European health agencies". TechCrunch. Archived from the original on 2020-04-29. Retrieved 2020-04-22.
36. ↑ "China launches coronavirus 'close contact' app". BBC News. 11 February 2020. Archived from the original on 28 February 2020. Retrieved 7 March 2020.
37. ↑ Chen A. "China's coronavirus app could have unintended consequences". MIT Technology Review. Archived from the original on 27 May 2020. Retrieved 7 March 2020.
38. ↑ "Gov in the Time of Corona". GovInsider. 19 March 2020. Archived from the original on 20 March 2020. Retrieved 20 March 2020.
39. ↑ Manancourt V (10 March 2020). "Coronavirus tests Europe's resolve on privacy". POLITICO. Archived from the original on 20 March 2020. Retrieved 20 March 2020.
40. ↑ Tidy J (17 March 2020). "Coronavirus: Israel enables emergency spy powers". BBC News. Archived from the original on 18 March 2020. Retrieved 18 March 2020.
41. ↑ Bünte O (18 March 2020). "Corona-Krise: Deutsche Telekom liefert anonymisierte Handydaten an RKI" [Corona crisis: Deutsche Telekom delivers anonymized cell phone data to RKI]. Heise Online (in Deutsch). Archived from the original on 24 March 2020. Retrieved 25 March 2020.
42. ↑ "Moscow deploys facial recognition technology for coronavirus quarantine". Reuters. 21 February 2020. Archived from the original on 22 February 2020. Retrieved 20 March 2020.
43. ↑ "Italians scolded for flouting lockdown as death toll nears 3,000". Pittsburgh Post-Gazette. Archived from the original on 20 March 2020. Retrieved 20 March 2020.
44. ↑ "Kreative Lösungen gesucht". Startseite (in Deutsch). Archived from the original on 24 March 2020. Retrieved 23 March 2020.
45. ↑ Dannewitz J (23 March 2020). "Hackathon Germany: #WirvsVirus". Datenschutzbeauftragter (in Deutsch). Archived from the original on 27 May 2020. Retrieved 6 March 2022.
46. ↑ Staff (8 April 2020). "Lockdown is working, suggests latest data from symptom tracker app". King's College London News Centre. Archived from the original on 11 October 2020. Retrieved 20 April 2020.
47. ↑ Lydall, Ross (4 May 2020). "Three million download app to track coronavirus symptoms". Evening Standard. Archived from the original on 11 October 2020. Retrieved 8 May 2020.
48. ↑ Whyte A (21 March 2020). "President makes global call to combat coronavirus via hackathon". ERR. Archived from the original on 24 March 2020. Retrieved 23 March 2020.
49. ↑ 49.0 49.1 "Hospital readiness checklist for COVID-19". euro.who.int. 2020-03-25. Archived from the original on 2020-04-23. Retrieved 2020-03-27.
50. ↑ Checklist for hospitals preparing for the reception and care of coronavirus 2019 (COVID-19) patients (Report). European Centre for Disease Prevention and Control. 2020-02-26. Archived from the original on 2020-05-06. Retrieved 2020-03-27.
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