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March 13, 2020

From Containment to Mitigation of COVID-19 in the US

Author Affiliations
  • 1The Permanente Medical Group, Kaiser Permanente, Oakland, California
  • 2The Permanente Federation, Oakland, California
  • 3Kaiser Permanente Division of Research, Oakland, California
JAMA. Published online March 13, 2020. doi:10.1001/jama.2020.3882

Coronavirus disease 2019 (COVID-19) is a respiratory illness that results from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.1 Following initial reports of disease outbreak in China, COVID-19 has spread worldwide with cases identified in at least 67 countries across 6 continents.2 On March 2, California Governor Gavin Newsom announced $20 million in funding and mobilization of the state’s emergency management system to counteract COVID-19. In addition, 171 patients with SARS-CoV-2 infection were evacuated on February 5 to a US Air Force base in California following exposure on a cruise ship. These patients, who were asymptomatic or only mildly symptomatic, were transferred to local hospitals using a containment strategy.3 When a small number of infected patients are in concentrated locales, containment strategies (ie, quarantine) can halt the spread of infection by isolating infected or exposed individuals from the general population.4 However, disease containment requires the use of airborne isolation rooms, personal protective and other disposable equipment, and significant numbers of health care personnel. As COVID-19 spreads both in the US and around the world, it may not be possible to care for all patients in this manner.

The advent of multiple new COVID-19–positive cases in the US who lack identifiable travel history or exposure signals that community transmission of SARS-CoV-2 has started and is occurring outside the containment zones of hospitals.1 Because these patients were not preemptively identified as persons under investigation, multiple community members and health care workers were exposed to SARS-CoV-2. As a result, hospital personnel have been furloughed under quarantine while they are evaluated for symptom onset and evidence of infection. These events not only affect the hospitals providing patient care to suspected and confirmed COVID-19 cases but also limit the personnel for adjacent emergency departments (EDs), intensive care units, and inpatient wards. It is critically important that the strategy for slowing the spread of the COVID-19 pandemic change from containment to mitigation. Mitigation approaches seek to: (1) slow the further spread of the virus, (2) reduce the anticipated surge in health care use, (3) provide patients with the right level of care to maximize the likelihood that the majority of patients will only require time-limited home isolation, (4) expand testing capability to increase available hospital capacity, and (5) tailor isolation to minimize transmission of SARS-CoV-2. Without rapid uptake of these approaches across hospitals, COVID-19 will pose a critical risk to an already strained health care system.

Emerging data indicate that SARS-CoV-2 is primarily spread by droplets, is likely to be more easily transmitted than seasonal influenza based on an R0 of 2.0 to 2.5, and can spread through asymptomatic or minimally symptomatic individuals who would not normally seek medical care or evaluation.1,5 Eighty percent of patients infected with SARS-CoV-2 have minimal or mild symptoms.2 Combining these characteristics and the emergence of community transmission, it is likely that silent spread has already occurred in multiple US locales. As a result, COVID-19 containment is no longer realistic and further emphasis on containment strategies may have the unintended consequence of hampering effective health care delivery for patients infected with COVID-19 and others who require general hospital care. At Kaiser Permanente, emergency management and preparedness teams are focused on developing a COVID-19 mitigation program (Table) based on good clinical practice, available evidence, and past experience. Whether this program will effectively achieve mitigation remains unknown.

Table.  Key Elements of a Proposed Plan for Coronavirus Disease 2019 Community Spread Mitigation in Kaiser Permanente Northern California
Key Elements of a Proposed Plan for Coronavirus Disease 2019 Community Spread Mitigation in Kaiser Permanente Northern California

Within acute care settings, the focus will be on minimizing disease transmission. Because SARS-CoV-2 is transmitted primarily by droplets, the proposed plan will focus on ensuring that reliable droplet precautions are used. Personal protective equipment will include the use of a surgical mask, disposable gowns, gloves, and protective eyewear. This approach is intended to simplify the workflow and preserve the use of enhanced airborne transmission precaution equipment like N95 masks and controlled or powered air-purifying respirators for patients with diseases like tuberculosis. Full airborne isolation precautions will continue to be in place for high-risk procedures including endotracheal intubation and bronchoscopy. All single rooms in the hospital would be available to accommodate droplet isolation, preserving the limited number of negative-pressure rooms for patients requiring true airborne isolation. Patient transport, including via emergency medical services, should similarly use droplet precautions. COVID-19 mitigation also requires that patients who are asymptomatic or who only have mild symptoms of viral respiratory infection will be asked to stay in isolation at home until they are well (ie, resolution of fever, improvements in cough). Household family members will be advised to avoid close contact while the patient is symptomatic. Patients isolated in the home may still receive specific SARS-CoV-2 testing based on clinical or epidemiological considerations. Similar to the approach used for an influenzalike illness, patients would be advised not to attend work or school until symptoms are resolved.

If patients’ symptoms progress, the proposed plan suggests that remote care could be delivered through telephone or video conferencing and treatment protocols to ensure social distancing when appropriate. For patients with progressive or more severe symptoms, designating specific sites for outpatient evaluation, such as clearly identified ambulatory clinic sites, free-standing structures (eg, tents), or mobile testing units could minimize exposure to health care workers and other individuals. Patients would be able to initiate self-transport or emergency medical service–based transport to EDs as needed. SARS-CoV-2 testing must be made available for inpatients and outpatients, similar to current rapid testing protocols for influenza, to establish the extent of community spread and ensure the optimal use of single room isolation for EDs and hospital units. According to the proposed plan, hospitalized patients with infectious symptoms would be cared for within single rooms following existing protocols for droplet precautions. In the case of a surge in the number of affected inpatients, placing multiple patients within a single room could occur if all are known to be positive for SARS-CoV-2. Through ongoing monitoring of hospital capacity, dynamic assessments will determine if additional sites such as mobile hospital units will be necessary. Restrictions to patient visitation would be similar to those that were in place for the H1N1 influenza pandemic, in which symptomatic and nonfamily members were asked to avoid hospital visitation. Patients who experience a resolution of their symptoms at home could return to work or school as is the practice for seasonal influenza. Hospital-based isolation would continue until discharge or based on testing recommendations issued by the US Centers for Disease Control and Prevention (CDC).

Even though health care worker furlough policies are effective during a containment phase, they are ineffective in the presence of ongoing community spread during which staff may be as likely to be exposed to infection outside the health care setting as within it. The proposed plan will follow similar protocols to those in place for influenza exposure. Personnel with workplace exposures to patients with suspected or confirmed COVID-19 should self-monitor for fever, cough, and other symptoms. If they become ill and are confirmed not to have COVID-19, personnel would remain off work until the resolution of fever and until their other symptoms begin to improve. Health care personnel with confirmed COVID-19 should be off work as per CDC guidelines.

Health product vendors are notifying hospitals that medical supplies may become limited for both COVID-19–specific and other general supplies. Personal protective equipment may become severely limited, underscoring the importance of following isolation protocols consistent with the mechanism of spread of the virus to maintain availability. Communication and coordination between the private hospital system and federal, state, and local authorities will be of the utmost importance. COVID-19 is undergoing community transmission in California and elsewhere in the US and has critical implications for the health care system. Shifting from a containment strategy to a mitigation approach, as suggested in the proposed plan, could allow optimization of health care delivery under the expectation of personnel and supply shortfalls in an already strained health care system. Clear guidelines shared across hospitals and states could help improve the ability to maintain a capable and sustainable approach for all patients. Pandemics bring much uncertainty. But what is certain is that the ingenuity of the public health authorities in partnership with hospital systems will be critically important to shift the strategy to meet the requirements of this evolving epidemic.

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Article Information

Corresponding Author: Stephen M. Parodi, MD, The Permanente Medical Group, Kaiser Permanente, 1950 Franklin St, Oakland, CA 94612 (stephen.m.parodi@kp.org).

Published Online: March 13, 2020. doi:10.1001/jama.2020.3882

Conflict of Interest Disclosures: None reported.

Funding/Support: This work was supported by The Permanente Medical Group and grant R35GM128672 (awarded to Dr Liu) from the National Institute of General Medical Sciences.

References
1.
US Centers for Disease Control and Prevention. Coronavirus disease 2019 (COVID-19): situation summary. Accessed March 2, 2020. https://www.cdc.gov/coronavirus/2019-ncov/summary.html
2.
Wu  Z, McGoogan  JM.  Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China.  JAMA. Published online February 24, 2020. doi:10.1001/jama.2020.2648PubMedGoogle Scholar
3.
Jernigan  DB; CDC COVID-19 Response Team.  Update: public health response to the coronavirus disease 2019 outbreak—United States, February 24, 2020.  MMWR Morb Mortal Wkly Rep. 2020;69(8):216-219. doi:10.15585/mmwr.mm6908e1PubMedGoogle ScholarCrossref
4.
Hellewell  J, Abbott  S, Gimma  A,  et al.  Feasibility of controlling COVID-19 outbreaks by isolation of cases and contacts.  Lancet Glob Health. 2020;S2214-109X(20)30074-7. Published online February 28, 2020.PubMedGoogle Scholar
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Bai  Y, Yao  L, Wei  T,  et al.  Presumed asymptomatic carrier transmission of COVID-19.  JAMA. Published online February 21, 2020. doi:10.1001/jama.2020.2565PubMedGoogle Scholar
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    2 Comments for this article
    EXPAND ALL
    COVID-19 Can Still Be Stopped in the USA
    David Booth, PhD | www.YosemiteProject.org
    The authors wite "As a result, COVID-19 containment is no longer realistic and further emphasis on containment strategies may have the unintended consequence of hampering effective health care delivery for patients infected with COVID-19 and others who require general hospital care."

    No! While mitigation must be done also, containment must not be abandoned! China has already shown that containment can be done at scale, with aggressive tracking, testing and isolation.

    Even now, we could still stop the COVID-19 epidemic in the USA if we had the right leadership, which we obviously have not had so far.
    It would have been many times easier and less expensive if effective measures were taken many weeks ago. But it still can be stopped now through:

    - Mass testing, using inexpensive sample pooling. Sample pooling (a/k/a group testing) can quickly screen many thousands using very few tests. We cannot fight this epidemic blindfolded! Drive-through testing is already being done in some areas. Mass testing could be done at supermarket entrances and other places people need to go, or even house-to-house. It is unconscionable that the CDC is still focused on individual testing rather than fast, inexpensive group testing.

    - Aggressive tracking and isolation. China used 1800+ teams of five, to track every suspected case! The National Guard could help. This is a national emergency - that's what they're for.

    - Daily testing of all front-line workers. Not just healthcare workers, but anyone else who is likely to be exposed to COVID-19, such as police and grocery store clerks. Again, this can be done cheaply, using very few tests, with sample-pooled mass testing.

    - Mandatory testing at all borders. Test everyone entering the country, with mandatory limited contact and daily follow-up testing for 14 days. Again, cheap and fast with sample pooling.

    - Mandatory testing could even be implemented as needed within the USA for travel between certain areas, or as a precondition for participating in particular activities.

    - Social distancing and appropriate quarantine (obviously).

    - Mandatory masks and hand sanitizing for all activities that require close proximity or touching shared objects, such as public transportation, air travel, grocery stores (think shopping cart handles).

    - Eliminating disincentives for testing and isolation compliance, such as wage loss and deportation and privacy threat.

    The federal government has failed in its leadership so far against COVID-19, allowing the infection to take root in almost every state. So unfortunately the states would probably have to initially take the lead on this, and then pressure the federal government to do it nationwide.

    David Booth, PhD
    www.BowDontShake.org
    CONFLICT OF INTEREST: None Reported
    READ MORE
    As Containment of COVID-19 has Failed, the Only Option is Responsible Management
    Michael McAleer, PhD (Econometrics), Queen's | Asia University, Taiwan
    The COVID-19 disease has proved to be fast and elusive in societies worldwide (1-4).

    Few countries have governments that have acted quickly, openly, and decisively, sometimes using necessarily extreme measures, at least by normal standards.

    Most countries worldwide continue to report rapidly increasing cases of the disease where it has not been contained.

    By mid-March 2020, the US Government finally seemed to have appreciated the serious devastation that COVID-19 can inflict on society.

    The present paper provides an excellent summary of containment and mitigation of COVID-19 in the USA.

    As containment has failed, the only
    option is to manage the spread and the resulting consequences in a responsible manner.

    Several Governors have taken the lead at the State level, and the Federal Government is contributing using federal powers.

    The fight has only just begun in the USA.

    References

    1. Sharfstein, Joshua M., Scott J. Becker, and Michelle M. Mello (2020), Diagnostic testing for the novel coronavirus. JAMA. Published online March 9, 2020. doi:10.1001/jama.2020.3864.

    2. Wang, C.J., C.Y. Ng, and R.H. Brook (2020), Response to COVID-19 in Taiwan - Big data analytics, new technology, and proactive testing. JAMA. Published online March 3, 2020. doi:10.1001/jama.2020.3151.

    3. Wu, Z.Y. and J.M. McCoogan (2020), Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China. JAMA. Published online February 24, 2020. doi:10.1001/jama.2020.2648.

    4. Wong, J.E L., Y.S. Leo, and C.C. Tan (2020), COVID-19 in Singapore - Current experience: Critical global issues that require attention and action. JAMA. Published online February 20, 2020. doi:10.1001/jama.2020.2467.
    CONFLICT OF INTEREST: None Reported
    READ MORE
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