Responding to the Winter COVID-19 Surge: What Governors Can Do

Introduction

The Winter Surge

More Americans are now contracting COVID-19 and being hospitalized than at any point during the pandemic’s prior peaks. The national death toll is over 300,000 and climbing quickly, making COVID-19 the leading cause of death in the United States, topping heart disease. In most states, transmission continues at very high levels. The virus is now much more ubiquitous in communities, making normal activities like going to work, dining out, shopping, and visiting loved ones much more dangerous.

Although vaccine distribution has begun, vaccines will not be available to the general public for some time, and therefore will not have a large effect on community transmission in the near term. As colder weather arrives and the holiday season begins, the risk of COVID-19 infection is further increasing as people are being driven indoors, where transmission is far more likely.

The Immediate Threat to the Hospital System

The uncontrolled transmission of COVID-19 that has been occurring in many parts of the country is putting an enormous stress on our hospitals – in urban areas and rural areas, where capacity is much more limited. As that happens, insufficient beds, equipment, and trained personnel will make it impossible to treat severely ill COVID-19 patients at the standard of care we have come to expect. This threatens to reverse the hard-won gains of doctors and nurses in learning how to reduce mortality over the last several months.

A steep and prolonged surge in COVID-19 cases has already caused many hospitals to cancel elective procedures and visits, potentially resulting in a decline in health outcomes from other conditions, as well as increased deaths. As in the spring, procedures like cancer treatments and heart surgeries could be delayed and cancelled. Simply put, many more people will likely die both directly from COVID-19 and from a lack of access to other important care if we allow COVID to overwhelm our hospitals.

To avoid the most drastic consequences of a prolonged surge in COVID-19 to lives and livelihoods, and to combat the threat to the hospital system, immediate, targeted measures must be taken to curtail the pandemic.

Elements of a Targeted Response to Save Lives and Flatten the Curve

Governors have a shared interest in protecting peoples’ health and livelihoods during this pandemic. Building on the recently released Call to Action to Defeat COVID-19 (supported by a bipartisan assembly of Governors representing one in three Americans), they should take targeted action to (1) prevent unchecked transmission of the virus by strengthening public health measures and restricting high-risk activities, (2) protect hospitals from becoming overwhelmed so that they can continue to provide high-quality care for both COVID-19 and non-COVID-19 patients, and (3) flatten the curve to a place where transmission can be controlled.

Priority Actions

With those goals in mind, if COVID-19 daily incidence and test positivity rates in a state or locality indicate uncontrolled spread, Governors and local officials should take the following targeted actions to reduce cases and hospitalizations:

• Require that masks be worn in indoor public environments and workplaces if they have not already done so.
• Restrict or close indoor activities in environments that have been shown to be especially dangerous for transmission, such as bars, indoor dining, gyms, and indoor gathering spaces, including indoor places of worship and indoor entertainment venues.
• Limit indoor gatherings to 10 people or fewer.
• Strongly encourage businesses and the federal government to provide paid leave to employees who are experiencing symptoms, as well as those who need to isolate or quarantine so that employees are better able to follow public health guidance that will break chains of transmission and bring COVID-19 case numbers back down.
• Provide social and mental health supports to people during quarantine and isolation by linking to social service agencies.
• Work with Congress and state legislatures to provide emergency economic relief for establishments that cannot maintain their businesses under this model during the winter.
• Agree on a common and simple risk-alert level categorization for every state, county, and zip code, with associated minimum closures at each level.
• Allow, encourage, and provide resources to public health departments to release guidance for hospitals to implement crisis standards of care that help to stretch hospital resources, including staff, and make care provision as equitable and ethically defensible as possible in times of severe resource constraint.
• Increase staff capacity at hospitals by recalling doctors and nurses back into service, drawing on trained personnel at nursing and medical schools, and using the National Guard, as appropriate, to staff staging and other areas.

Testing and Tracing

To detect outbreaks early and contain spread, Governors should take the following steps now to increase testing and improve contact tracing capabilities:

• Increase diagnostic testing in hospitals and especially in areas with outbreaks through mobile testing sites or local capacity to enable isolation and referral for timely treatment. Advocate for additional federal resources to support this capacity.
• Identify and prioritize high-risk settings (e.g., nursing homes, carceral facilities) and develop shared guidance for screening tests at those sites to accompany the federal government’s distribution of point-of-care tests to states.
• Advocate for the federal government to:
  • Build on the current federal purchase contracts for tests by contracting for additional point-of-care tests and laboratory testing capacity, and by providing clear guidance on the distribution of, use of, and response to these tests.
  • Provide funding or testing resources for states to enable regular screening tests at identified high-risk settings to detect outbreaks early and contain spread.
• Recognizing that contact tracing efforts are likely to be less effective when there are more than 10 cases per 100,000 population per day, focus contact tracing on clusters and screening in higher risk settings, and continue to hire contact tracers and improve contact tracing capabilities that can be used to reduce transmission once the current rising curve is flattened.

Vaccines and Treatments

With the emergency authorization of vaccines, Governors should take the following steps to ensure their equitable distribution and effective uptake:

• Partner with the federal government, local governments, healthcare providers, health plans, and community organizations to:
  • Ensure appropriate and effective prioritization of who will get the vaccine;
  • Assure vaccination site availability and transport for all priority populations to have timely access;
  • Enhance data systems to track and report on vaccinations and identify gaps;
  • Build communication campaigns and community engagement to inform and educate the public, particularly groups such as communities of color who may have limited trust in or access to medical services.

To save lives and ease the burden on hospital systems, Governors should take the following steps to allocate and administer monoclonal antibody therapies (mAbs), which can prevent hospitalizations when administered early:

• In collaboration with the federal government, Governors should work with local public health authorities to identify gaps in effective and equitable access to mAbs for the highest-risk patients.
• Governors should seek guidance from the federal government to implement best practices for timely referral and infusion of mAbs for high-risk COVID-19 patients soon after they develop symptoms, through access to testing, specialized infusion sites, and mobile or home infusion for patients who cannot easily reach the sites.
• Advocate for Medicaid and private payers to clarify that providers will receive adequate reimbursement with no patient copays for administration of mAbs, and for Medicare to increase availability of home and mobile infusion where needed.

Messaging

Finally, to engage Americans in their own rescue, Governors should provide clear messaging to members of the public about how they can control the spread of COVID-19 and keep themselves, their families, and their communities safe this winter, including:

• Wear masks indoors and outdoors in all public and private spaces outside of your home, and maintain 6 feet of distance in public even if wearing a mask.
• Patronize restaurants by ordering takeout or by eating outdoors if they have that option; and avoid eating or drinking indoors at restaurants and bars.
• Telework where possible, otherwise wear masks indoors and maintain 6 feet of distance between you, co-workers, and customers.
• Exercise outdoors or at home, avoiding indoor gyms.
• Participate in religious gatherings virtually.
• Minimize non-essential travel.
• Celebrate the holidays with household members only, and for those who gather with non-household members, follow CDC guidance to minimize the risk of transmission.

As we move into a dark winter, these evidence-based measures will reduce caseloads, save lives, and better prepare states and the country for more rapid recovery and renewal.