Lets Try Containment Again

By: Foss Tighe
April 27, 2020

Biden would jump to the left,
And Trump thinks he is right.
With No hands on your lips
Strap your mask on tight.
But its the nasal swab
That really drives you insane.
Lets try Containment again!
Lets try Containment again
!
Sung to the tune of “Lets do the time warp again”

In Epidemiological terms, containment is the process of identifying new cases of infection as early as possible and then isolating the infected person and ascertaining a list of the infected person’s recent contacts. Each of the infected persons contacts are then notified that they may have been infected and they too should quarantine themselves.

To be successful, testing needs to be readily available and rapid. Infected people and their contacts need to believe that their isolation and quarantine is effective and in the best interests of their community. The greater community needs to provide material and emotional support to those in isolation and quarantine so that the process can be successful. The process is very labor intensive.

The process is most easily implemented early in an infectious disease outbreak.

Short video by Partners In Health – The organization helping the State of Massachusetts with its Contact Tracing program.

Why Try Now?

Flattening the curve has greatly reduced the loss of life in the initial wave of infections, but a growing number of public health experts predict new waves of infections in the months ahead. The current level of “lock down” and social distancing has reduced the outbreak in the United States to a level that does not exceed the enhanced capacity of our health care system. But even with these restrictions, over the past 2 weeks, the United States has consistently seen approximately 30,000 new cases detected each day, and approximately 2,000 deaths each day. Shortly the number of deaths will surpass the number of Americans killed during the Vietnam war.

Yet even this level of lock-down and social distancing does not appear sustainable. Social discord is growing over the on-going lock-down and the accompanying economic damage. All the while, the prospect of a vaccine is still, at best, over a year away.

There is always hope that a theraputic breakthrough will be found, but the initial most encouraging medications have failed to meet our hopes for a medical panacea. Some Epidemiologists have begun to whisper about herd immunity as a possible resolution to the pandemic. However, herd immunity relies on the assumption that once someone recovers from infection they have some form of immunity, at least for some period of time. The World Health Organization (WHO), however, has warned against basing policy on the assumption that infection gives people immunity. They cite the lack of evidence regarding immunity, and the nagging reports from South Korea, where about 2% of previously infected and apparently recovered people have again tested positive for the virus. This phenomenon may be a function of testing flaws, or a “Reactivation” of the original infection rather than a new infection. But in any case, it casts some doubt on the strength of any immunity gained by recovering from a COVID-19 infection.

If the infection itself does not produce long term immunity, it means developing a vaccine that can do so may be more challenging. It may turn out more like the annual flu vaccine, which is not 100% effective and needs to be given annually. So even a vaccine may not prove a silver bullet.

Why should we turn to containment now? Because it is the only thing that we have that has good evidence that it works and it can be attempted now, with the tools we have.

The Success Stories:

There are a small handful of countries around the world that have contained or are in the process of containing their coronavirus outbreak. The the table below lists Coronavirus statistics from some of the countries considered successful in their coronavirus containment.

CountryTotal
Cases
Active
Cases
Total
Deaths
Tests/
Million
Taiwan429133625,000
New Zealand14692701925,000
Australia672010518320,000
Iceland179217410135,000
South Korea10,738173124311,000
Data from https://www.worldometers.info/coronavirus/ as of 4/27/2020 8:30 AM EDT

Each nation’s path is slightly different. Taiwan has been the most successful. They started with aggressive containment from the very start of the outbreak. They never had to shut down their economy and have managed their cases through contact tracing and quarantine. For more details see my post What does containment looks like?

Daily New Cases from New Zealand – https://www.worldometers.info/coronavirus/country/new-zealand/

New Zealand and Australia have followed similar paths. After initial outbreaks, mid-March for Australia and late March/Early April for New Zealand, a strict lockdown and aggressive social distancing brought the outbreak down. Both countries are using contact tracing and quarantine to track all existing cases to break the chain on infection and prevent further outbreaks. New Zealand has been explicit in its plans to eradicate the infection from New Zealand, while Australia has been more focused on controlling the current outbreak.

Iceland had it’s outbreak from mid-March to early April. Iceland’s suppression of the outbreak relied on very extensive testing. Iceland tops the world in tests per million population. This allowed Iceland to identify the majority of its cases quickly, followed by contact tracing and quarantine of effected individuals.

South Korea had its initial outbreak in late February through early March. Their initial outbreak was quite large and very specific to a particular religious group. South Korea used very aggressive testing in the effected population along with contact tracing and quarantine to bring that outbreak under control. Of all the countries listed above, South Korea still have the largest number of active cases, but trends show a consistent decline in active cases.

What about Singapore?

Missing from the list is the city-state of Singapore. Until recently Singapore had been included in many media lists of countries successful in infection containment, but recent spike in new cases puts their containment in jeopardy. This illustrates that containment is not a one time action, but requires on-going vigilance to maintain. Especially in a world where successful containment among your neighboring nations is not the norm.

Containment Easier for Island Nations:

All of these nations have one thing in common. With the exception of South Korea, all of these nations are islands. South Korea, on the bottom of the Korean peninsula, is only bordered by one other country, North Korea. Since that border is very tightly controlled, in many ways South Korea is virtually an island nation like the others in the list.

There is no doubt that being physically disconnected from other nations makes effective containment easier on a nation by nation basis. Containment through case detection and contact tracing would likely be harder in non-island nations, but with international cooperation it should not be considered impossible.

One exciting possibility for these nations is that these nations could substantially open up their economies, commerce and even travel among themselves. Mostly easily imagined among Australia, New Zealand, Taiwan and South Korea. It might be more challenging for Iceland to participate in this “Coronavirus Contained” group.

Containment and contact tracing the the United States:

Containment through contact tracing is being included in discussions in the United States. The US Coronavirus Task Force document Opening Up America Again criteria call for states to have the following testing and contact tracing capabilities prior to opening up.

  • Ability to quickly set up safe and efficient screening and testing sites for symptomatic individuals and trace contacts of COVID+ results
  • Ability to test Syndromic/ILI-indicated persons for COVID and trace contacts of COVID+ results
  • Ensure sentinel surveillance sites are screening for asymptomatic cases and contacts for COVID+ results are traced (sites operate at locations that serve older individuals, lower-income Americans, racial minorities, and Native Americans)
    https://www.whitehouse.gov/openingamerica/#criteria

Many individual states have started implementation of more aggressive contact tracing programs. Massachusetts was one of the first states to announce such a plan. Senators from Massachusetts and Michigan have announced plans for a “National Containment Corps” to address this need nationally.

This needs to be a high profile movement. In addition to the contact tracers, many thousands of volunteers will likely be needed to delivery food and medicine to those under quarantine. As a society, we need to endorse this effort, build momentum, and make it the social norm to comply with this effort. Containment through contact tracing and quarantine is a thousand fold more efficient than essentially quarantining everyone. With effective contact tracing, only those who are genuinely as risk for infection through exposure to another known infected person needs to limit themselves. If successful, the rest of us can substantially reduce social distancing and the economy can be opened up at little risk of new spikes. We should be demanding that our government, at all levels, endorse and get started on this important missions. A few months ago, people might have questioned the cost effectiveness of such a program. But a few billion dollars would probably buy the United States a Cadillac version of the contact tracing and quarantine for a mere fraction of the cost of the various economic recovery programs launched so far.

The initial attempt at containment of coronavirus in the United States failed for a number of reasons. The details of that can be analysed later. We need to move beyond those initial failures and tackle the task at hand with the money and creativity that we know our nation possess.

Lets try Containment Again!

5 thoughts on “Lets Try Containment Again

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