Travel Restrictions for Limiting Community Disease Spread (Version 1)

Aaron Green, Chen Shen and Yaneer Bar-Yam, Travel restrictions for limiting community disease spread, New England Complex Systems Institute (May 9, 2020). link to NECSI site here

Travel restrictions (Cordon Sanitaire) are a vital tool in the fight against COVID-19 to reduce transmission to zero (#CrushTheCurve) and restore normal activity. By limiting travel, gains from local efforts to stop the disease can be preserved because new outbreaks arising from travelers can be prevented. Without such restrictions any effort to stop the outbreak in one place will be undermined by imported cases. Waiting for all areas to achieve low enough case counts would substantially delay restoring economic activity. Travel restrictions should apply to travelers from a high risk area to any other area, including other high risk areas. 

The status of a designated area (zone) should be identified as being in one of three colors: Green, Yellow and Red. 

  • Green zone—no new local (within community) transmission for 14 consecutive days. All new cases, if any, occur in individuals who were effectively isolated from the moment they entered the zone (imported travelers);
  • Yellow zone—no new local transmission for 14 consecutive days, but there are new cases identified using contact tracing, or the zone is adjacent to red zones;
  • Red zone—community transmission identified within the last 14 days.

A zone should be a district that is naturally or artificially separated from its neighboring districts. A zone should only have controllable traffic transitions with neighboring zones. If two geographical regions have a shared border that cannot be effectively controlled, they should be considered as one zone. Zones can have a nested structure where the largest unit is a country or state. Zones should reduce the number of border crossings as necessary to ensure proper transport guidelines and quarantine are followed.

The most basic zone border protocol includes: 

  • No unnecessary travel into any zone from a yellow or red zone.
  • 14 day quarantine for any individual arriving with permission into any zone from a yellow or red zone.
  • Provision for transit travel if complete isolation protocols (air port transit isolation, not leaving a land vehicle, not leaving a designated road area) during transit across a zone. Where feasible, services should be provided for transit travel with extreme precautions.
  • Import of goods by delivery to a designated cargo border location and transfer of the goods to internal control. 

A more complete zone land border control infrastructure enables a wider range of travel options, with appropriate control to prevent transmission.

Temporary border control locations are necessary right before entering and exiting zones. These may be newly formed or converted service areas or weigh stations. To these areas add hygienic and clean air self-service facilities that protect both the traveler and the community. For freight/cargo drivers, they should be required to perform essential activities (like dining) in these service areas to minimize exposure in the zone. Such self-service facilities will also help travelers from one green zone to another green zone if their route has to cut through yellow/red zones. Negative pressure ambulances should also be deployed at such service areas for medical emergencies, and for out-of-zone individuals seeking medical care in in-zone hospitals. 

Zones must set up a system for travelers from yellow/red zones to notify zone local authorities in advance about their arrival, indicated by signs along the transit road and online, including registering their name, license plate number, and ETA. Upon arrival at the entry service area, travelers are redirected directly to isolation facilities. Ideally, the isolation facility should be close to the border control service area, and they can also serve as the temporary lodging space for officials working at the service area, to minimize their contact with the community. Symptomatic testing (fever and questionnaire) should be standard at all crossing points. Where available, RT-PCR rapid nasal swab tests should be performed. Test results should be added to official travel documents when available. Arrivals without registration are denied entry.

Travel restrictions should be based on local needs. There are four aspects of travel: (1) Arrivals into a zone, (2) essential worker travel, (3) transit across one zone to get to another, (4) delivery of goods.

I. Arrivals into a Zone

In general, travelers arriving from yellow or red zones to any other zone (green, yellow or red) should be quarantined or self-isolate with supervision for 14 days. Travelers originating in green zones may not need to be quarantined if they are coming from another low risk area. In order to avoid the need for more stringent restrictions, travelers should have official or otherwise reliable itinerary records (origin, intended destination, zones they have traveled through) and tests with results (if possible) from zones they have passed through on their journey. A system for official travel documents should be developed. 

Patients from a yellow or red zone seeking medical services should be encouraged to find treatment in their home zone. If they are unable to obtain services in their home zone they may seek treatment in specifically designated clinics or hospitals that have the proper protocols in place to receive inbound patients who may be infected. Travel from the zone boundary to the service center should be supervised and documented for tracing purposes.

II. Essential worker travel

In order to separate transmission in different zones, individuals who regularly travel between two zones for work and living quarters must do one of the following:

  • Temporarily change work or living quarters so that they are within the same zone;
  • Follow strict guidelines for isolation from local population in one of the two zones. This may include living alone or working without contact with other employees;
  • Change roles so that remote work is possible;
  • Take a temporary leave of absence with pay.

Where this is not possible, frequent screening tests are necessary. In a case where individuals who live or work in boundary regions between two zones that are both of reduced risk, exceptions may be made for essential workers. Essential workers who are COVID-19 positive should quarantine in their home zone.

Under exceptional circumstances essential workers may arrive or be imported into a zone with zone authority approved quarantine and work plans that ensure extremely low risk for transmission employment conditions. 

III. Transit or thru traffic

Transit airport, highway and major road traffic should not be blocked. However, precautions must be taken at entrance into a zone and pit stop locations. If a zone decides to allow an individual from a higher risk zone to travel across to get to another zone it would be prudent to track the vehicle for enforcement of regulations and tracing purposes. Designate controlled routes and pit stops to ensure through-zone transit is safe for residents.

Through-zone travelers should avoid pit stops if possible. When necessary, wear a mask, practice distancing and thoroughly wash hands. Add pit stop to travel itinerary for tracing purposes.

IV. Delivery of goods

Freight should have clear destinations and itinerary. Set up quarantine areas for freight drivers to go once they have delivered their goods. They either return to their origin the same day or wait in a quarantine area until their next job.

Packages should undergo sanitation or quarantine for a period of time to deactivate any virus on fomites and prevent transmission.

In general, for transport into a yellow or red zone, freight drivers must quarantine upon return to their home zone. Freight and cargo transport without quarantine upon return is possible, provided the following conditions are met:

  1. There are no symptoms of illnesses;
  2. Vehicle operators do not leave the vehicle, with exceptions for designated and reliably managed pit stop locations;
  3. Loading and unloading is carried out by the customer;
  4. The vehicle operators leave the zone again within 24 hours.

For trips that last longer than 24 hours, upon return they should quarantine while they wait for the next transport job.  If they want to reenter their zone without restrictions they must quarantine or self-isolate for 14 days.

References

  1. https://www.china-briefing.com/news/chinas-travel-restrictions-due-to-covid-19-an-explainer/
  2. https://www.craigak.com/sites/default/files/fileattachments/administration/page/10896/07-02.pdf
  3. https://www.gw-world.com/news/press-releases/news/update-coronavirus-covid-19/
  4. https://www.iatatravelcentre.com/international-travel-document-news/1580226297.htm
  5. https://www.china-briefing.com/news/wp-content/uploads/2020/04/CHINA-Travel-Entry-COVID-19-Policy-By-Province-As-of-27-March-2020.jpg
  6. https://www.wsj.com/articles/chinas-new-coronavirus-policies-disrupt-u-s-air-cargo-operations-11585859298

Growing Safe Zones

This is a working draft.

COVID-19 has proven difficult to contain with standard measures in today’s hyper-connected world. The virus often becomes infectious before symptoms are observed and there are high rates of asymptomatic carriers who spread the virus unwittingly. In addition, infectious viral particles exist airborne and in feces and the high transmission rates between individuals, lead to the recipe for the pandemic we have today. 


Blanket travel restrictions and stay at home policies have made an impact in reducing the spread of the disease and “flattening the curve,” However, this has come at great expense to economic and social activity, since we have to treat everybody as being potentially infectious. Moreover, the measures implemented so far are not enough to “crush the curve.” 

We are far from herd immunity, as soon as blanket restrictions are lifted the virus will begin to spread exponentially again. In the absence of a vaccine or therapeutics, pursuing herd immunity is not an ethical option as many millions of people may die and the long-term risks of the disease are still uncertain. 

We must take action now to allow communities to safely get back to economic activity. We cannot simply wait for a vaccine or an antiviral drug to be developed as the timeline and efficacy are still uncertain. 

The virus is a tough opponent, but it is not invincible, nor is it everywhere. The virus is only spread through contact with infectious individuals and the surfaces they have infected. Proper protocols can be put into place to keep uninfected communities safe. Proper protocols can also be put in place to make sure that infected communities can handle and contain the virus until the infectious period is over and they are no longer a threat to safe communities.

There is precedence in history for communities effectively dealing with viral epidemics for which no vaccines or antivirals exist. Quarantine, isolation and travel restrictions date back to the biblical times and have long been a method of preventing the spread of epidemics. The term quarantine originated in Venice during the Black Death where ships would need to wait for a period of 40 days before entering the city and was an effective method for preventing the spread of disease. More recently, during the Spanish flu of 1918, travelers entering new townships would either need to submit to quarantine or be escorted through the township to make sure they did not leave their vehicle. Cities that implemented early and prolonged social isolation in the United States during the Spanish flu faired markedly better than their counterparts who did not. 

While our population centers have become more dense and transport has become more widespread than the past, isolation and travel restrictions are still possible – and effective.

We propose a federated model for growing Safe Zones to mitigate community risk of infection. A Safe Zone is defined as a community with a well-defined border in which everyone follows Safe Zone policies. Safe Zone communities can connect and interact with one another through Safe Protocols. If a member community of the federated Safe Zone becomes infected, they can be isolated until the infections stops. Once they demonstrate that they are again a Safe Zone they can rejoin the federation.

Safe Zones is a bottom up approach and requires support at the regional, state and national levels to coordinate and enforce quality testing, tracing and supply chain methodologies. Blanket travel restrictions, isolation, testing and mask wearing should remain in place for all zones which are not Safe Zones.

Strategic resources include protective masks, thermometers, universal symptom questionnaire, cleaning agents and disinfectant, viral test kits, PCR machines, antibody test kits

Community Compact

In order to be designated a safe zone the community must:

  • Demonstrate that there is no active infection in the safe zone through viral testing.
  • Conduct ongoing surveillance testing (wastewater, random viral testing, daily thermal readings, universal symptom reporting)
  • Designate and establish of isolation area/s to place infected individuals in the event of an outbreak.
  • Designate and establish area/s to quarantine quarantine inbound visitors and people planning to establish residence in the Safe Zone.
  • Provide ongoing reminders and education about safe zone policies.
  • If the safe zone becomes infected: quarantine infected individuals and monitor closely. In order to be deemed a safe zone again, they must demonstrate no community transmitted infection for an amount of time equal to two times the virus incubation period (~14 consecutive days).
  • When interacting with other safe zones verify that they are complying with safe zone policies prior to easing border restrictions. While safe zones can connect to grow the original safe zone structures should continue to exist in order to mitigate the scale-risk of an outbreak.
  • When interacting with other Safe Zones that become infected close borders to the zone and provide support as necessary until they become a Safe Zone again.
  • When dealing with people who are following no Safe Zones protocol or unknown protocols treat as though they are infected.
  • Essential goods entering the Safe Zone from a non-verified zone should be quarantined and sanitized. Certificate of origin as well as travel itinerary should be inspected.

Administrative level responsibilities

Local level: Lead community-level safe zone initiatives following Safe Protocols. Enforce checkpoints at borders. Coordinate purchasing and distribution of state and county-sourced strategic resources needed to implement safe zones policies as necessary.

Metropolitan level: Support township-level safe zone initiatives. Enforce travel restrictions between townships as necessary. Coordinate purchasing and distribution of state-sourced strategic resources needed to implement safe zones policies as necessary.

Region level: Support township-level safe zone initiatives. Enforce travel restrictions between townships as necessary. Coordinate purchasing and distribution of state-sourced strategic resources needed to implement safe zones policies as necessary. 

State/Provincial level: Support county-level safe zone initiatives. Enforce travel restrictions between counties as necessary. Coordinate purchasing of national-sourced strategic resources needed to implement safe zones policies as necessary.

National/Federal level: Support state- and provincial-level safe zone initiatives. Enforce travel restrictions between states and provinces as necessary. Coordinate purchasing of strategic resources needed to implement safe zones policies as necessary. Coordinate testing and ensure interlocking goals at different levels are met through pandemic testing board.

International level: Support nation-level safe zone initiatives. Enforce travel restrictions for infected nations.

Cross-functional and inter-level fusion cells with daily calls may aid in communication and remove some of the communication inefficiencies of chain of command.

******

NOTES

Considerations: 

  • safe circles has bad connotations when the group size is small. Zone is a term that seems more scale independent w/r to connotation. 
  • The size of the safe zone needs to be thought about. Ideally the safe zone would contain essential services as well but in catchment areas of things like hospitals and sanitation systems can be quite large.
  • Toll between regions to pay for testing? 
  • Incentivize people to stay in unit until next to another safe unit. Recognize that we benefit from having more people in the federation. 
  • Cost of growing federation must be lower than cost of staying independent
  • Do not incentivize people to get sick so that they have the incentive to get antibodies. What is to stop bad actor from crossing the safe zone to say “f* you.” 
  • Sometimes you need to do stuff that you dont really want to to come up with solutions. 
  • What about areas that are not economically independent like hawaii that can do safe zones but currently rely heavily on tourism?

References:

Handbook of COVID19 prevention and treatment

Roadmat to Resilience. Harvard University. https://ethics.harvard.edu/files/center-for-ethics/files/roadmaptopandemicresilience_updated_4.20.20_0.pdf

Roadmap to responsibly reopen America. Paul Romer. New York University.

What models cannot tell us

https://www.endcoronavirus.org/projects-1/what-models-can-and-cannot-tell-us-about-covid-19

Community based analysis

https://www.endcoronavirus.org/projects-1/eliminating-covid-19-a-community-based-analysis

Essential Coronal Virus Guidelines https://assets-global.website-files.com/5e62f57a6f9734c5e7879c84/5e6ee4bda4e7ff2b9816afac_Essential%20Coronavirus%20Guidelines.pdf

Alert color codes

Individual Community Govt https://assets-global.website-files.com/5e62f57a6f9734c5e7879c84/5e6ee4bc7ef394ee6a554c32_Individual%20community%20and%20government%20guidelines.pdf

Massive testing 

Pandemic Math

https://necsi.edu/pandemic-math

Superspreader events – types of superspreaders

https://necsi.edu/first-thoughts-on-superspreader-events

Transition to extinction – pandemics are serious and global travel connectedness is exacerbating the issue

https://necsi.edu/transition-to-extinction

Linked shared space model- forming closed social Zones

https://necsi.edu/a-linked-shared-space-model-for-covid-19-transmission-and-its-prevention

While the smallest of these is not normally a stand-alone grouping, the others appear as natural community sizes in hunter-gatherer societies: Lehmann, Lee, and Dunbar (2014) give values of 42.8 ± 18.0SD (bands), 127.3 ± 43.8 (clans), 566.6 ± 166.2 (mega-bands) and 1727.9 ± 620.6 (tribes)… sympathy groups are 11.3 (+/-6.19)

https://www.sciencedirect.com/science/article/pii/S109051381730209X

Why a 5-week lockdown can stop covid-19 – need to get past the 2X incubation period (this line not in paper) with negative testing to call your zone safe

https://necsi.edu/why-a-5-week-lockdown-can-stop-covid-19

What can be done to stop the wuhan coronavirus pandemic – multiscale approach. Some communities for self-contained cells limiting transportation within and between them. No in no out policy. Deffinition of community: street office in urban area, or town government. Three types of community A, no cases; B, one case in past 14 days; C two or more cases and potential spreading.Uninfected (Community A) strategy: “Prevent outside in-put:” mobilize the community, provide health education andspecific information, improve the environment, stockpile sup-plies, and manage the case of people who live in the commu-nity returning from affected areas (with detailed description).Potentially Exposed (Community B) strategy: “Prevent in-side spread, prevent outside output” include all above (A) andmanage close contacts and sanitation.Infected (Community C) strategy: “Prevent inside rampage,prevent outside output” include all above (A and B) andblockade the area and limit gatherings within the community

How community response stopped ebola. – Contact tracing wasn’t working because people were becoming infectious and infecting their community before anything could be done about it. Each member of a community screened daily for fever and isolated if they show early symptoms. Exponential decline40-50 percent compliance results in declining cases. As those communities realized, just like isolation of individuals does not mean abandoning them, neither does community quarantine mean abandoning them. It is an opportunity to focus care, preventr people from getting infected and stop the disease. If this had been the earliest response to the outbreak, many more lives would have been saved and unimaginable suffering, as well as the economic and social disruption, would have been prevented.

The same principles of community-based intervention can be applied to a wide variety of potential diseases. Understanding the lessons of Ebola’s containment will allow for these policies to be implemented more effectively in the future, reducing the death toll of future epidemics and limiting the possibility of a larger pandemics.https://medium.com/complex-systems-channel/how-community-response-stopped-ebola-a13a28a674d0

Beyond contact tracing – 40% compliance with community level policy leads to negative case growth. 60% rapidly ends it https://aarongreendotblog.files.wordpress.com/2020/04/77531-beyondcontacttracing.pdf

Travel Restrictions for Limiting Community Disease Spread (First Draft)

This was a working draft on travel restrictions. Final draft was published here

Travel restrictions are a vital tool in the fight against COVID-19 and a necessary strategy to #CrushTheCurve. By limiting travel between zones the transmission of the disease can be greatly limited and allows for the ability to identify and protect safe zones.

Travel areas can generally be denominated in three different colors, Green, Yellow and Red:

  • Green zones – are areas with no confirmed cases or no new confirmed cases for 14 consecutive days;
  • Yellow zones – are those with new confirmed cases within 14 days – but the total new cases are no more than 50, or with cumulatively more than 50 confirmed cases – but no cluster epidemic within 14 days; and
  • Red zones – are those where the cumulative number of confirmed cases have exceeded 50 cases, and a cluster epidemic was recorded within the last 14 days.

Borders between zones need to be enforced to ensure policies are followed. Zones should reduce number of border crossings as necessary to ensure appropriate staffing to ensure quarantine and proper transport guidelines are followed.


Zones can create their own travel restrictions based on local needs. In general any travelers coming from yellow or red zones should quarantine or self-isolate for 14 days. Domestic travelers may not need to be quarantined if they are coming from another low risk area. Travelers should travel with cards that show their itinerary (origin, intended destination, zones they have traveled through) and tests with results (if possible) from zones they have passed through on their journey. Border staff should consider marking travel documents with color-coded stickers (red for covid19 symptoms or traveling from hardest hit areas, yellow for US, green for the rest). Ideally, a full suite of testing is done on all travelers traveling between zones including thermal recording, symptom questionnaire, nose swab, throat swab and tracing registration. Swab test results should be added to travel card when available.

Transit vehicle traffic

  • Restrict traffic coming from yellow or red zones. Any traveler coming from a yellow or red zone should be quarantined or should self-isolate with supervision for 14 days.
  • Exceptions for essential workers may be granted but quarantine is strongly advised. Essential workers who are COVID19 positive should quarantine in their home zone.
  • Avoid pit stops if possible. When necessary, wear a mask, practice distancing and thoroughly wash hands. Add pit stop to travel itinerary for tracing purposes.

Freight and cargo transport:

  • Set up quarantine areas for freight drivers to go once they have delivered their goods. They either return to their origin the same day or wait in a quarantine area until their next job.
  • Packages should undergo sanitation or quarantine for a period of time to deactivate any virus on fomites and prevent transmission.
  • Freight and cargo transport without self-isolation is possible, provided that:
    • there are no symptoms of illnesses
    • the vehicle operators do not leave the vehicle
    • loading and unloading is carried out by the customer
    • the vehicle operators leaves the country again within 24 hours
  • For trips that last longer than 24 hours If the vehicle operator went to a yellow or red zone on their journey, upon return they should quarantine while they wait for the next job or if they want to reenter the safe zone quarantine or self-isolate for 14 days.

SOURCES
https://www.china-briefing.com/news/chinas-travel-restrictions-due-to-covid-19-an-explainer/https://www.gw-world.com/news/press-releases/news/update-coronavirus-covid-19/
https://www.iatatravelcentre.com/international-travel-document-news/1580226297.htmhttps://www.china-briefing.com/news/wp-content/uploads/2020/04/CHINA-Travel-Entry-COVID-19-Policy-By-Province-As-of-27-March-2020.jpghttps://www.wsj.com/articles/chinas-new-coronavirus-policies-disrupt-u-s-air-cargo-operations-11585859298

Coronavirus Guidelines for Cleaning and Disinfecting to Prevent COVID-19 Transmission

Aaron Green, Chen Shen and Yaneer Bar-Yam, Coronavirus guidelines for cleaning and disinfecting to prevent COVID-19 transmission, New England Complex Systems Institute (April 9, 2020). link to NECSI website

COVID-19 is mainly transmitted via aerosols and droplets and can exist on fomites—surfaces, equipment, utensils, fabric, hair, dust and other particles—for days. The disease may be spread when people touch contaminated surfaces and then touch their face. Regular cleaning and disinfecting of surfaces that are frequent touch-points helps to prevent disease spread.

Cleaning removes germs, dust, dirt and impurities from surfaces. Some forms of cleaning also kill germs. Even when cleaning doesn’t kill germs, removing them from the immediate environment where people are located reduces the risk of spreading infection.

Killing germs by disinfection should be performed after cleaning to further reduce the risk of spreading infection. The coronavirus causing COVID-19 can be killed by soap, alcohol and chlorine bleach.

More specifically: SARS-CoV-2 can be neutralized by lipid solvents including ether (75%), ethanol, chlorine-containing disinfectant, peroxyacetic acid and chloroform except for chlorhexidine. A list of disinfectants for SARS-CoV-2 can be found on the EPA’s website.

Time also kills viral particles. Current information indicates that over a period of hours, low density viral particles on cardboard become inactive, and over a period of a few days, they become inactive on hard plastic and metal surfaces. However, systematic inactivation on a variety of fomites and conditions is not yet well understood. This includes its dependence on the quantity of viral deposits, temperature, humidity, and other ambient conditions. For high density or large areas, the reliability of inactivation decreases and chemical disinfection is highly recommended. Washing and the use of disinfectants also should allow time for the effects to occur. Applying disinfectant and leaving on surfaces before rinsing is important.

In general there are two types of surfaces that need to be cleaned and they require different protocols. Soft, porous materials include carpeting, rugs, towels, clothing, sofas, chairs, bedding, soft fabric toys (i.e., stuffed animals), etc. Hard non-porous surfaces include stainless steel, floors, kitchen surfaces, countertops, tables and chairs, sinks, toilets, railings, light switch plates, doorknobs, metal/plastic toys, computer keyboards, remote controls, recreation equipment.

Supplies

  • Waterproof gloves such as latex, nitrile or dishwashing
  • Soap/detergent, warm water, clean towels, leak-proof plastic trash bags
  • Disposable gowns for extensive cleaning related tasks including taking out industrial trash
  • Face mask
  • Goggles (optional to prevent reactions to cleaning and disinfecting solvents)
  • Disinfectants

General Guidelines for Cleaning

  • Discard rather than clean or disinfect highly contaminated items.
  • Immediately throw away all disposable cleaning items
  • Wash hands frequently, including after emptying waste baskets and touching tissues and similar waste.
  • Wash your hands thoroughly with soap and water for at least 20 seconds or use an alcohol-based hand sanitizer that contains at least 60% alcohol

Clothing and Other Soft, Porous Materials That Can Be Laundered

  • Place materials in a sealed plastic bag until laundering
  • Launder using hot water and a detergent, preferably containing color-safe bleach
  • Dry on high heat

Soft, Porous Materials That Can Not Be Laundered (Carpets, Couches, Other Porous Surfaces)

  • Vacuum to keep dust from spreading into the air
  • Spot-clean spills of bodily fluid promptly following safe procedures
  • Deep clean carpets while avoiding splashing as much as possible
  • Use steam cleaners to clean carpets and other porous surfaces as needed

Hard, Non-Porous Surfaces

  • Follow labeled instructions on all containers
  • Clean surface with soap and water to remove all visible debris and stains
  • Rinse surface with clean water and wipe with clean towel
  • Apply the disinfectant. To effectively kill the virus, make sure the surface stays wet with the disinfectant for at least 10 minutes before wiping with a clean towel. If an EPA registered disinfectant is not available a 2% chlorine bleach solution can be used. Take care with alcohol based disinfectants as they tend to evaporate quickly and may not fully disinfect if instructions are not followed
  • Rinse with water and allow surface to air dry. Rinsing following use of a disinfectant is especially important in a food preparation area
  • Mop heads should be cleaned with soap and hot water and sanitized with an EPA-registered disinfectant or bleach solution and allowed to dry. Consider using single-use, disposable mop heads or cloths as an alternative
  • Remove gloves and place in a trash bag and discard
  • Wash hands after removing gloves and handling any contaminated material, trash or waste

Outbreak guidelines for high-risk institutions (version 2)

Aaron Green, Chen Shen and Yaneer Bar-Yam, Outbreak guidelines for high-risk institutions version 2, New England Complex Systems Institute (March 13, 2020). link to NECSI website

Retirement communities, dormitories, nursing homes, rehabilitation facilities, psychiatric wards, and prisons are High-Risk Institutions for diseases transmission. COVID-19 is a rapidly transmitting disease requiring hospitalization in about 20% of cases, ICU care in 10%, and resulting in death in 2-4%. Complications rapidly increase for persons 50 years old and above with comorbidities such as heart failure and coronary artery disease further increasing risk. COVID-19 can transmit even with mild symptoms (coughing, sneezing or elevated temperature) and perhaps before symptoms appear. Reducing the likelihood of transmission is imperative in high-risk institutional environments as found in China’s Rencheng Prison and South Korea’s Cheongdo Daenam hospital. Here are guidelines for prevention by introducing barriers to transmission from outside.

General Rules

Visitors

  • Discourage non-essential visitors.
  • Restrict points of entry and position someone at entrances to query the purpose of the visit and ask if the visitors have any symptoms, have recently travelled to areas of active transmission, or have been exposed to people with symptoms. Check for fever with non-contact IR forehead thermometer.
  • Visiting should be spaced at intervals to avoid crowding. 
  • Best practices guidelines should be posted in easily readable format and relevant languages in public spaces for employees, residents and visitors to see.

Hygiene

  • Recommend to residents and employees to avoid directly touching high frequency touch-points. These include door handles, elevator buttons, sinks, table tops and frequently handled machinery, equipment, electronic devices and other items. Recommend electric doors, or carrying tissues, paper towels, plastic bags or other disposables.  
  • Increase cleaning and sanitizing of all high frequency touch-points.
  • Increase checking and ensuring that soap dispensers and paper towels in bathrooms remain adequately supplied throughout the day.
  • Provide hand sanitizers at entrances, exits and high-traffic locations.
  • Provide tissues and sterilizing alcohol based wipes.

Employees and Corporate Environment

  • Educate staff and their families, as well as residents and their families, of Coronavirus transmission and prevention
  • Ensure employees know that when they have even mild symptoms they should not be at work locations or in-person meetings and they will be paid and not penalized for sick days. Set up a reporting system for any cases
  • Ensure employees have appropriate health insurance policies so that they will not be afraid to seek out care when they have symptoms, even mild ones. 
  • Prepare for employee substitutions in case they become ill individually or collectively. 
  • Stay abreast of current information and advisories
  • Replace in-person office meetings with virtual

Enhanced rules for Areas of Active Transmission

It is essential that High Risk institutions follow Safe Zone practices and remain disease free. 

Visitors

  • Promote a Safe Zone strategy that defines the perimeter of the institution as a boundary across which contacts that may lead to viral transmission do not occur. 
  • If at all possible, avoid outside contact and encourage the use of text, phone and videoconference to communicate.
  • Where visitors are necessary consider setting up a separate area for visitor meetings, including enough space for everyone to remain at a safe distance (6 ft), video links for virtual contact and glass partitions.
  • The use of masks (if possible N95) may be encouraged even if there are no signs of outbreak.
  • Deliveries should be made by single drivers who do not have symptoms of the disease and have not recently (within 14-21 days) had known exposures. 
  • Whenever possible, no contact deliveries should be dropped off in a space that does not require entry into the facility. 
  • It is highly advisable that people allowed entrance into high-risk institutional environment have been recently tested with negative results.

High Contact Activities, Including Dining

  • Prohibit gatherings and meetings and eliminate non-essential services and programs involving travel or contact.
  • Prohibit activities and games that involve multiple individuals handling the same objects (card games such a bridge, mahjong, billiards). 
  • Consider limiting overly strenuous exercise which may tax cardiovascular systems and increase vulnerability to medical events. 
  • Close shared facilities such as libraries and sitting rooms.
  • Where residents normally engage in excursions outside the institution, discourage or prohibit individual resident excursions outside the institution. 
  • Strongly discourage residents from visitors. 
  • Where excursions or visitors take place, consider the risk levels and need for careful monitoring of symptoms. 
  • Assist residents to obtain goods and services through online ordering or arrange for safer shopping. 
  • If possible, replace dining services with no-contact in-room food delivery service.  
  • Where dining services are necessary
    • Sanitize areas of contact after each individual use, including table top, chair arm rest, menu. Or use washable or disposable tablecloths and menus.
    • Wait and service staff should avoid contact and proximity.
    • Stagger dining times to avoid crowding and sitting arrangements to avoid face-to-face dining.
  • Where contact is essential for service provided, careful handling protocols should be made including effective ventilation, gloves, disposable overgarments, and masks. 

Employees, Facilities and Corporate Environment:

  • Emphasize to employees that their actions outside of work can lead to transmission of infection risking the lives of residents. Even if the disease has a low risk to them, any contact with individuals or surfaces in non-safe areas is extremely dangerous for those in the High-Risk facility. They should take responsibility and limit off-work non-safe contact to a minimum
  • Encourage employee adoption of Safe Space protocols at home limiting their contact and others who live with them with individuals and surfaces that are not safe and record which employees are following them.
  • Engage with local medical facilities to coordinate rapid testing of residents and employees for Coronavirus.
  • Partition facilities to separate zones, limiting employees and residents from crossing from one zone to another, so that in case one zone becomes infected, the others will not before detection and response limit contagion.
  • Transfers of residents in or out of the institution should follow safe space requirements with attention to point of origin, point of destination, contact with those performing the transfer, and the vehicles that are involved. 
  • When bringing in new residents or starting new employees that are not coming from a Safe Zone quarantine for 14-21 days.
  • Where possible, arrange facilities for residential accommodation of employees within this or another Safe Zone. 
  • Arrange partnerships with sister institutions to follow Safe Zone practices for transfers and response to any outbreak.
  • Arrange for office staff to work from home, develop protocols so that this is possible.
  • Avoid clustering in elevators. Elevators should not take more than half of their carrying capacity
  • If A/C must be used, disable re-circulation of internal air. Clean/disinfect/replace key components and filters weekly
  • Check the engineering design of ventilation system to determine if air flows connect air from different rooms. Develop mitigation or alternative ventilation processes. 
  • Examine the facilities for areas with no or little ventilation such as a basement or staircase, inform residents of the potential risks of extended stays in such areas.
  • Deploy air purifiers using HEPA filters around the facility. 
  • Identify internal or external facilities that can be used for 14-21 day quarantines.
  • Prepare plans for action if a case of Coronavirus is identified. This may include locking down every individual in the facility (or in external facilities that may be used for this purpose) so that they cannot infect each other, including employees and residents. 

COVID-19: An Opportunity to Revisit and Implement Localism Policies

The COVID-19 pandemic is shaking up the global economy.

Major supply chain disruptions have begun to surface as quarantines established in major manufacturing centers to thwart the spread of the disease are having economic effects. In addition, Western nations have finally come to the realization that COVID-19 will not be contained. The result: widespread investor panic has ensued with >$6 trillion in market losses over the past week. Many citizens in Western countries are finding empty shelves in grocery stores as people prepare for unknown consequences of the pandemic.

Many are seeking effective leadership and sensible policies to guide us through this crisis.

Now is the ideal time for systemic change of international policies. Prior to the pandemic panic, the inertia of the globalism imperative was too great to meaningfully influence. However, with the slowing of the global economy there is opportunity now to right course. Additionally, the attention and funding that are being directed at this problem we may achieve the activation threshold to move from one local minimum (modern globalism) to a more stable global policy.

In a recent paper Joseph Norman (@normonics), Yaneer Bar-Yam (@yaneerbaryam) and Nicholas Nassim Taleb, (@nntaleb) highlight the threat of novel pathogens to modern interconnected societies and advocate for localism policies to reduce mobility and spread of the virus. We have seen China implement these policies on regional and local levels to great effect with decreasing numbers of reported new daily cases amidst a severe outbreak of 78,000+ individuals, buying the world time to slow the spread of the disease.

Given the fat-tailedness of infectious diseases, it is inevitable that globalism will eventually lead us off a cliff. Globalism exacerbates the spread of infection and increase the likelihood that a pandemic will be devastating. While it is unlikely that this SARS-CoV-2 will be the end of us, it highlights the downsides of interconnectedness. Moreover, there will always be a novel pathogen around the corner.

Localism policies will need to take root if we are to have any chance of long-term survival as a species.