Five Steps to Eradicate COVID-19

This will be the first, and maybe only, time we break what I’ve called the ‘OSINT HK Voice” of Royal We’s and allow myself to speak in the first person. The first thing I wrote for this platform was an explainer on what the Imperial Report Means for Asia. Ferguson’s Imperial report has now been proven wrong on at least two key premises but is correct about one for any country not practicing a strategy of COVID19 eradication.

The first premise they were wrong about was that this virus is uncontainable. Hong Kong, Taiwan, Vietnam, South Korea, China, Macau, Australia, New Zealand prove this wrong (and Singapore will likely soon rejoin the group). The second premise was the entire point of #BendTheCurve – for complex reasons we still don’t fully understand, hospital over-capacity has proven rare even in places with high attack rates. 

Where the model is correct is that not persuading an eradication strategy will likely mean that a country will fight a losing battle against this virus for years. The choices are either ‘do nothing’ or various suppression strategies that turn off and on until herd immunity (~70%) is reached. Except there are worrying signs that immunity, either from infection or a vaccine, might prove short lived. In that nightmare scenario of repeat infections, the only strategy any locale should take at this still-early stage is eradication: extinct COVID19 like we did SARS. 

Any country that is not actively trying to eradicate COVID-19 within the next two to three months has explicitly set their nation on a course to fight a losing battle with COVID-19 for years. Eradication might not be possible everywhere, but we are running out of time to make a try for it. Centralized Quarantine – practiced in China, Vietnam, and Singapore – brought the R0 down to 0.38 in Wuhan. Everywhere should at least make an effort to try. Right now, most countries are making the same mistake Wuhan did in the early days: a family member was just sent back home to wait for a test result. This leads to household infections and more home deaths.

Let me detour for a short thought experience: how would we have fought this pandemic in 1990 – less than a decade after PCR tests were invented? In this scenario we have COVID19 tests, but they’re limited. We would also have real time data reported only slightly slower than today, comparatively high levels of international travel compared to any other point in history [to spread this globally very quickl], and the computational power for epidemiologists to run rudimentary SIER models to provide policy options. What would clinical diagnosis look like without mass testing? What interventions would be taken without having a perfectly clear picture of who is infected?

The point of this thought experiment is that I see – around the world – an unnecessary reliance on technology to plan and execute a public health strategy to eradicate this virus. There are very smart people trying to plot their way out of this mess in the Philippines, India, the UK, the US, and elsewhere not planning their next move until testing capacity expands to X threshold level. They sit on lockdown waiting for technology to fix this. From where I sit, in a place that has one of the highest testing per capita levels in the world, is akin to people denied Google Maps forced to rely on the old paper type for the first time in recent memory and finding themselves lost without it. Except they forgot the paper maps even exist.

The outbreak in China has been building up for about two months before the first PCR test was available. For the next month afterwards, the tests were plagued with false negatives and China faced the same logistical and supply issues seen everywhere else. Higher tech (perhaps too high tech) solutions would come by the end of March, but doctors and public health experts were mostly flying blind until mid-February. They stamped COVID19 out despite a peak that was likely >100k infections. 

Centralized Quarantine in Wuhan

What they did then should be the basic eradication blueprint everywhere. Western epidemiologists should start computing what these interventions would look like in different places to give the right numbers and contexts. However difficult it might be, an eradication blueprint looks like this:

  1. Don’t Wait For Mass Testing. In an ideal world, every country would have been prepared for 20k tests/day before the virus reached their shores like Korea. We do not live in that ideal world. The goal of mass testing is both objectively a Good Thing and a cognitive roadblock. The same places that say “we can’t re-open without mass testing” and hoping that phone-based contact tracing are going to get them out of this hole still haven’t thought through what to do with confirmed cases that aren’t sick and close contacts. Clinicians need to asking what a 1990 diagnosis would look like (i.e., a context like now in many places where testing is a luxory).
  1. Don’t Rely on Lockdowns. There is reasonable debate about what this term means, but here it means sending >90% of workers home and letting protected delivery drivers take care of most groceries and medicine. In red zones, no one should be going outside much for about three months. When and if they do, it should be considered high risk and masks are mandatory. At the same time, lockdowns need to be reframed as buying time to develop a local eradication policy. There is no evidence that lockdowns alone, however, can drive the R0 below 1.
  1. Centralized Quarantine with four groups: confirmed infected, no test result but symptomatic, close contacts, and confirmed COVID19 cases with either mild or no symptoms. The goal is to remove these people not just from the population, but from households to cut every potential transmission chain. Generally, the lower the risk the more comfortable these options (i.e., hotel rooms for close contacts). There is no beating this virus without isolating all potentially infectious carriers and smashing every transmission chain you can uncover. The role of testing here is to bring all those who need it to the right place, release those who test negative as quickly as possible, and move place confirmed cases to sites where they will have better monitoring
  1. Travel Restrictions. Look at any COVID19 outbreak map and you’ll see waves of infections moving out from cities into places that now have few, or manageable, caseloads. Generally speaking, (a) those outward waves need to be prevented from spreading any further and (b) places with few, or no, cases need to be protected. As Taiwan and Vietnam show, the best way to contain an epidemic in its infancy is to start with low numbers and keep them low. Just as the ‘fleet sails at the speed of the slowest ship,’ entire polities are at risk from their weakest sub-national governments who can not, will not, or do not contain their outbreaks. Successful suppression efforts must be protected. Generally, travel restrictions work best (or only work) when baseline numbers are small.
  1. Think Global, Act Local. What is usually a trite number sticker contains a lot of truth right now in many contexts. The situation looks hopeless at the national level in many countries right now. Focus on getting the area you live in under control and protected from waves spreading out of red zones. Centralized Quarantine looks impossible when you think about the numbers at the national level, but they’re likely a lot more manageable at the local level (how many college dorms, coliseum and gym floor space for cots, and empty hotel rooms does your city have?). Domestic travel restrictions should prevent red zones from exporting cases to other places and county-, city-, and state-level automatic quarantines for new arrivals, close contacts, suspected cases, and non-sick confirmed cases. 

I cannot promise this will work. Too much time might have been lost in some places. What I am asking for – begging – is for modelers to start including intervention scenarios like this in their reports. Every country, province, and city needs to see an option – however unrealistic – to stamp this out in two to three months. Progress might be uneven globally or nationally, but that’s why domestic travel restrictions and quarantine are there to protect your hard-fought containment success. 

My fear is that the successful eradication efforts in places like Hong Kong, Taiwan, Australia, Vietnam and elsewhere will have been for nothing if the world can’t pivot to eradication. We are protected now with virtual lockdowns on international travel. Can this be sustained for more than a year? And what happens to the rest of our economies if Europe, the UK, and America are stuck in cycle of repeat lockdowns roughly every 90 days for the next 18-24 months? We all go down if the global economy crashes. We all lose if COVID-19 is just something we all have to learn to “live with.”

9 Replies to “Five Steps to Eradicate COVID-19”

  1. I agree 100% with the idea that we should be aiming for eradication, soonest.

    But I don’t see testing as having much of a role (if any) in getting that done. Reports are that current testing methods yield a lot of false negative results – on the order of 30%.

    I think the only answer for countries that already have a lot of COVID-19 is lockdown done right. We have to act as though anyone could be infectious, because that’s literally true.

    So what is lockdown “done right”? I’ll answer for my own country, the U.S., but probably a lot of other countries have similarities.

    Our biggest vulnerability is institutionalized populations. Nursing homes, hospitals of various kinds, and prisons. Places where large numbers of people live together in the care of other people who normally come and go.

    The people who come and go – the staff – need to stop coming and going for the duration of the lockdown. They all need to isolate from their own families and everyone outside the institution, and stay together for the duration of lockdown either in the institution or in a nearby hotel where nobody else stays and where maid service is suspended. Also, staff members who normally serve multiple institutions will have to serve only one during lockdown.

    Everyone else can and should go into lockdown with their households. But real lockdown means no in-person shopping. Ideally everyone would stock up beforehand on food and other essentials to last through the lockdown. During lockdown shopping would be by delivery only, with delivery workers taking precautions.

    Emergency responders should work out how to best handle their duties without spreading COVID-19. EMTs could be assigned as a team to an ambulance which is kept in the driveway of a team member during lockdown. Police could do something similar, entering their police stations during lockdown only if absolutely necessary.

    And last but not least, foreign travelers would have to be quarantined on arrival.

    How long would lockdown have to last? At least the longest known or estimated incubation period for this disease. Long enough for everyone who became infected before lockdown to feel enough symptoms to know they’re infected.

    Everyone who begins to experience symptoms during lockdown would need to report in. And of course they and those in their households would need to stay in lockdown longer.

  2. Oops, the length of lockdown might be governed by how long symptomless carriers can be infectious, if that is longer than the incubation period for those who eventually experience symptoms.

    Or if pneumonia visible on x-ray turns out to be a universal marker even for those who are unaware of any symptoms, maybe that could be used to separate the infected from everyone else.

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