On Jan. 7, 2021, the U.S. hit another grim milestone, for the first time recording over 300,000 new cases of COVID-19 and over 4,000 deaths from the infection in one day. Across the country, hospitals and intensive care units are now under enormous strain trying to treat so many sick people. And if a new, more transmissible variant of SARS-CoV-2, the virus that causes COVID-19, were to take hold in the U.S. as it has in the U.K., as seems plausible, our health system could pass its breaking point.

It’s all too easy to become numb to the toll and accept these daily figures as a new normal while waiting for the vaccine rollout to have an impact. Since the first vaccines were approved in Dec. 2020, we seem to have stopped talking about the rising cases and deaths. But we must not just accept this level of infection, suffering, and devastation for months on end while we wait until we reach vaccine herd immunity sometime in the summer or fall.

COVID-19 is a preventable illness. Many countries, like Australia, China, New Zealand and Taiwan, have practically ended community transmission of the virus and returned to a near-normal life, and they did so without using a vaccine. If we continue to see rising transmission, it will make it all the more challenging for vaccines to act as a tool that ends the U.S. pandemic.

There are five key actions we can—and should—take urgently to drive down viral transmission.

First, we need to get every American a high-filtration mask

Widespread mask wearing across the community is linked with lower transmission rates; face masks reduce viral transmission in two ways. First, they prevent infected people from spreading the virus to others (masks act as “source control”). This effect is particularly important for people who are infected but don’t yet have symptoms—they feel fine and so may be unaware that they are infectious. Second, masks can also help protect the wearer from inhaling virus-laden droplets or aerosols.

However, not all masks are equally effective at filtering out the particles that carry the virus. One recent study, for example, found that some masks (e.g. N95 masks and masks comprising two woven nylon layers and a nonwoven filter insert) do a better job than commonly used cloth and surgical masks. So, we need to urgently get these more effective “high-filtration” masks to all Americans. Dr. Abraar Karan at Harvard Medical School and his colleagues argue that the incoming Biden administration should invoke the Defense Production Act to urgently mass manufacture high-filtration masks and fund research to develop new mask designs.

We can learn from the remarkable success of South Korea and Singapore, where governments early on manufactured and distributed high-filtration masks (e.g. K-94 masks, the Korean equivalent of N95 masks) to all at no cost to its citizens. In Singapore, you can even get a high-filtration mask for free from vending machines. Why can’t the U.S distribute masks in this way to Americans too?

Second, schools and workplaces need to be made safer

On Jan. 20, 2021, it will be exactly one year since the first case of COVID-19 was confirmed in the U.S. It is unconscionable that in all this time we have still not made the necessary investments into schools and workplaces to make these settings safer. The science is clear on the steps that need to be taken—including ventilation, air filtration, spacing between people, universal masking, and reducing the density of people.

Third, we must protect our essential workers

It is a moral stain on this country that so many essential workers—including in clinics, hospitals, nursing homes, grocery stores, schools, factories, farms, and warehouses—have been infected and so many have died. While there is no accurate database on health worker infections, by Nov. 15, 2020, the CDC estimated that there had been 216,049 health care worker infections in the U.S. An investigation by Kaiser Health News and the Guardian found that nearly 3,000 U.S. health workers had died as of Dec. 23, 2020, of which around two-thirds were people of color. We’ve witnessed terrible scenes in which nurses and doctors have had to improvise their own personal protective equipment (PPE) out of trash bags, pool noodles, and snorkel masks.

It’s equally difficulty to quantify with certainty how many grocery or warehouse workers have been impacted by the virus, but Amazon says that from March 1 to Sept., 19, 2020, 19,816 of its frontline Amazon and Whole Foods Market employees tested positive or were presumed positive.

Enough is enough: every single essential worker in America deserves to be protected from COVID-19 with the highest quality PPE combined with the other measures described above to improve building safety.

Fourth, we need to urgently build a functioning nationwide “test, trace, isolate, support” (TTIS) system

The nations that have successfully controlled viral transmission, like Australia, China, Hong Kong, New Zealand, Singapore and Taiwan, have at least one thing in common: they have systems in place to efficiently identify infected and exposed people. This is crucial for controlling transmission, because it means infected people know they need to isolate (isolation means an infected person keeps away from others) and exposed people know they need to quarantine (quarantine means someone who might have been exposed stays away from others). The U.S. needs to emulate, not ignore, this success. The “support” component of TTIS is critically important—people need financial support to isolate or quarantine to replace any lost wages. North Carolina, for example, has such a support program in 29 counties, called the COVID-19 Support Services program, which provides money and delivers meals, medications, face masks, and hand sanitizers to people isolating or quarantining.

One powerful tool that could help control transmission in the U.S. would be widespread, frequent and accessible rapid antigen testing. These tests can identify contagious people before they get symptoms. I was one of over 50 U.S. public health experts who signed a Dec. 15 open letter to the federal government, led by Dr. Michael Mina at the Harvard T.H. Chan School of Public Health, to fund aggressive deployment of such tests, in order to “protect public health, allow safe in-school instruction, and to restore our economy.” The good news is that the letter has bipartisan support in Congress and is being seriously considered by the incoming Biden Administration as an effective public health initiative to stop the spread of the virus. Rapid Tests, the all-volunteer group directed by Mina advocating for rapid tests to be made legal and widely available, is working on pilot programs in various cities and states and is advising the CDC/HHS teams on the right testing strategy—with frequent, fast antigen testing as a national policy.

Fifth, the U.S. needs a “circuit breaker” to break the chains of transmission

I think it was a mistake for President-elect Joe Biden to rule out instituting a nationwide “circuit breaker”—that is, a short-term, national stay-at-home order. At the very least, we need circuit breakers at the state and city level in the highest transmission states.

Great Britain and Israel have recently instituted such circuit breakers in conjunction with their vaccination campaigns (the circuit breaker in Great Britain has already driven down transmission everywhere except North West England). There is strong scientific evidence and consensus that community-wide physical distancing can drive down transmission rates, particularly if adherence is high.

In many situations where COVID-19 is out of control, there is typically strong public support for stay-at-home orders—this is not surprising, given that people want to be protected from illness and death. In Great Britain, for example, a Jan. 5, 2021 public poll conducted by the public opinion and data company YouGov found that 85% of the public endorse the current lockdown, which was announced on Jan. 4, and 77% think it should have happened sooner. Nevertheless, research has shown that people living in low-income households are much less likely to be able to work from home under such restrictions, pointing to the critical importance of accompanying stay-at-home orders with financial and social support.

In July 2020, when daily new cases in the U.S. were just a quarter of what they are now, over 150 scientists, public health experts, and health workers signed a letter urging the country’s federal government to institute a nationwide circuit-breaker. The letter stated: “Right now we are on a path to lose nearly 300,000 American lives by December 1st. Yet, in many states people can drink in bars, get a haircut, eat inside a restaurant, get a tattoo, get a massage, and do myriad other normal, pleasant, but non-essential activities.”

We’ve now lost 380,000 Americans. The toll will keep rising unless we start treating COVID-19 as a national emergency that warrants aggressive public health actions.

 

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