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COVID-19

School of Public Health Expert Insights

A Plan for a Phased Reopening Guided by Public Health Principles

A report from the Johns Hopkins Center for Health Security aims to help governors navigate the process

April 17, 2020


The U.S. is collectively and eagerly awaiting Reopening Day.

In the context of the coronavirus pandemic nothing is certain—except that reopening will not happen in a day. It will take place over weeks and months, or longer, and will look different for every state, and likely for cities and towns as well.

In a new report, the Center for Health Security at the Johns Hopkins Bloomberg School of Public Health lays down a potential path for moving from strict physical distancing measures to phased reopenings of organizations and settings central to the functioning and vitality of communities.

The report, Public Health Principles for a Phased Reopening During COVID-19: Guidance for Governors presents a framework for risk assessment of virus transmission in connection with reopening nonessential businesses, schools and childcare facilities, outdoor spaces, public transportation, mass gatherings, and interpersonal gatherings.

“It is an effort to provide some of the foundation for decision making,” says Caitlin Rivers, PhD, a senior scholar with the Center for Health Security and a report co-author. “We don't say, ‘This is in and that's out,’ because so much of it will vary. But we do want to provide support to decision makers as they start to think through these decisions.”

Rivers discusses with Bloomberg School writer Jackie Powder how U.S. governors might begin to approach the complex decision making process on the road to reopening.

What are the key considerations for community health and safety in a reopening process?

We try to give a high-level assessment of the risk of transmission based on contact intensity, which is how much close contact any people would have in a given setting and the number of contacts. Places with a lot of people will be a higher risk. Then we also think about the modification potential. Some places there's not much you could do to really enable physical distancing, and other places it's more feasible and we think that should be a dimension of consideration as well.

Can you give examples of what reopenings in different types of spaces could look like?

In shared spaces like restaurants or workplaces, you could conceivably limit the number of people who are able to go in. You could also put in place physical barriers. I've seen pictures of restaurants in Asia that have plexiglass between the diners so that they can still share a table. Those kinds of interventions would be modifications that would reduce risk. But it would be more difficult to implement physical distancing measures with young children, for example, because they can't really adhere to those principles.

What is your advice to governors who are under enormous pressure to reopen?

I would keep in mind that although restarting economic activity and supporting people economically is a really pressing priority right now, the last thing we want to do is create the conditions that led to us having to stay home. We don't want that to happen again. This is a really critical phase--being thoughtful and careful about how to reopen.

We recommend that governors make a few moves when it's time and then wait and see what happens. We know any changes will not show up in the data for two to three weeks so you would want to wait at least that long to see whether you have done anything to start transmission again. And if you do see that, you should stop or you should go back to physical distancing. You shouldn't continue to layer on new community activities, so just really proceed with caution.

The report is targeted to governors, but stresses they should draw on a diverse group of stakeholders in making reopening decisions. Why is that important?

Different communities will have different capacities and they will also have different outbreaks. Some communities will be very well-resourced with their health care system and public health department so they might be in a position to handle a little bit higher level of transmission. Other places may have fewer resources and they really need to see lower levels of transmission before considering reopening. Governors need to have that context and that background in order to make good decisions.

The report not only talks about risk assessment for settings like businesses, schools, and retail but for personal events like birthdays, weddings, and funerals. How do they fit into the picture?

I think for the average person, one of the most difficult parts of this situation is the uncertainty and not knowing when to begin to plan these events or that big trip that you put off. That's not to minimize the actual suffering of people who have been affected by this virus and their family members, but I do understand that that uncertainty is also really unsettling. The truth is that nobody knows what these timelines are. There is a lot of possible futures, and it's hard to say which way it's going to go. So, we have to continue to live with some of that uncertainty for the time being.

Does reopening inevitably mean more transmission of the virus?

Our hope, which we laid out in the Roadmap to Reopening, is that we will be able to shift from community-level physical distancing to case-based intervention and that that shift will be the mechanism that we use to control transmission. But we have to expect that when we start to have more contacts in the community and spend more time in the community that there will be transmission opportunities. It's right that we need to be prepared for that possibility.

So how does reopening compare to a full return to normal?

We will still all need to take steps to reduce our personal risk and also the risk to others in our community. Vulnerable adults, people with underlying health conditions, and those who are older will still need to limit activity in the community. When we are able to spend more time in the community, and even now when we go grocery shopping or go to the pharmacy, we are already being asked to wear non-medical, cloth masks and that will continue. There will still be some activities that won't be available to us for the near future at least, which would be large gatherings. I don't expect to see stadiums full of people or large concerts in our near future.