Social Intervention by the Numbers: Evidence Behind the Specific Public Health Guidelines in the COVID-19 Pandemic

Population Health ManagementVol. 24, No. 3 Points of ViewOpen AccessCreative Commons licenseSocial Intervention by the Numbers: Evidence Behind Specific Public Guidelines in COVID-19 PandemicMichael P. Savage, David L. Fischman, and Mamas A. MamasMichael SavageAddress correspondence to: Michael MD, Thomas Jefferson University, 111 South 11th Street, Suite 6210, Philadelphia, PA 19107, USA E-mail Address: [email protected] Medicine, Pennsylvania, USA.Search for more papers this author, FischmanDepartment MamasCentre Prognosis Research Department Cardiology, Keele Stoke-on-Trent, United Kingdom.Search authorPublished Online:8 Jun 2021https://doi.org/10.1089/pop.2020.0180AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail IntroductionCoronavirus disease 2019 (COVID-19) has rapidly become a worldwide pandemic ushering global health economic crisis. In absence vaccines or definitive drug therapies, current strategies against rely on preventing transmission through nonpharmaceutical interventions such as social distancing proper hand hygiene. For practical perhaps ethical reasons, clinical efficacy these public measures managing pandemics not been demonstrated randomized controlled trials. Accordingly, guideline recommendations using are based primarily observational modeling studies expert opinion. A recent position paper from World Organization (WHO) graded quality evidence be low mitigating influenza.1 Nonetheless, have credited with slowing spread China west coast States.2–4 These apparent salutary effects mirror benefits similar observed prior influenza pandemics.5 Further confirmation importance come loosening practices subsequent rapid surge cases Sunbelt region States country attempted reopen.In addition general closure schools nonessential businesses, guidelines include series specific, quantitative that focus analysis (Table 1).6–8 Among explicit rules regarding interpersonal (6 feet), limitation group gatherings (10 people), duration quarantine exposed individuals (14 days), handwashing (20 seconds). received wide interest international medical community public. The goal is critically evaluate basis behind prominent role pandemic.Table 1. Recommendations Nonpharmaceutical Interventions Mitigate Interpersonal distanceQuarantine durationMass gatheringsHandwashing durationCDC66 feet14 daysVaries community?20 secondsWHO71 meter (?3 feet)14 daysCase-by-case basis40 60 secondsECDC8—14 daysDiscouraged without quantification20 40 secondsPCG——Avoid >10 people—Agreement OrganizationsSlight DiscordanceUniform ConcordanceNo Uniform RecommendationModerate ConcordanceStrength COVID-19WeakModerateWeakModerateCDC, Centers Disease Control Prevention; ECDC, European Centre Prevention Control; PCG, President's Coronavirus America (www.whitehouse.gov); WHO, Organization.Interpersonal Distancing 6 Feet SeparationThere lack unanimity among organizations recommended distance spacing 1). US (CDC) states, “COVID-19 spreads mainly people who close contact (within about six feet) prolonged period.”9 CDC recommends 6-foot between people. WHO 1 meter, only half CDC. contrast, 2-meter Kingdom while other countries recommend 1.5 meters.10,11The primary mode thought droplet when an infected person coughs, sneezes, talks during contact. Droplets refer larger expelled particles typically travel less than feet before falling ground. More controversial infective potential smaller viral-containing called “aerosols” (<5–10 mm diameter), which further stay airborne longer. measles virus tuberculosis familiar pathogens known via aerosols. capacity coronaviruses infect issue uncertainty.12The origin 1-meter rule endorsed stems work dating back 19th century Professor C. Flugge at University Breslau. Using plates various distances measure how far expiratory droplets travel, bacteria-containing were settle quickly. It was concluded infection within few “infector” unlikely.13 As late 1996, infectious isolation precautions concurred 3-foot distance, noting “do remain suspended air generally short distances, usually three less.”14 With new millennium came questioning old dogma respiratory infections (3 foot) recommendation. Olsen colleagues studied 100 had in-flight exposure severe acute syndrome (SARS) coronavirus.15 Of 23 passengers seated same row rows directly front symptomatic passenger unknowingly SARS, 8 (35%) subsequently developed SARS. 10/88 (11%) elsewhere became ill (relative risk, 3.1; 95% CI, 1.4 6.9). persons ill, 90% 36 inches away index patient, suggesting small viral responsible. Current now separation avoidance.6Whether sufficient under increased scrutiny. Quantitative samples taken 1, 3, patients detect greater concentration feet. Samples predominantly but humans.16 viruses may affected several factors. Enclosed indoor spaces often currents facilitate farther transport particles. pertain standing still. They do take into account aerodynamic introduced movement brisk walking, running, cycling, create slipstream carrying exhaled well beyond Recent emissions coughing sneezing result exhalation speeds up 30 meters/second clouds varying sized meters.17 Therefore, it appears there many conditions could exceed feet.The relevance observations presently uncertain biodynamics aerosols containing SARS-CoV-2 emerging. hospitalized evaluated Wuhan.18 Air positive 35% intensive care unit 12.5% wards. Notably, 4 meters. shown viable hours surfaces days.19 likely greatest enclosed poor ventilation. concerns expressed commentary supported 200 scientists urging update its guidance risk aerosol COVID-19.20These contemporary data, including reports COVID-19, suggest base recommending poor. Although argued practicable, no reassurance negligible distance. systematic review reduce reduced longer associated even benefit; estimated relative decreased 2-fold each additional distance.21 length can both safe pragmatic remains unclear. Analogous inverse square law radiation safety, what clear one moves source lessens progressively.Increasing aerosols, transmitted feet, reinforce mask wearing. Masks especially important settings where avoidance difficult. Harvard hospitals, universal masking workers significant reduction rate workers.22,23 Countries populace widely adopted face use experienced much lower rates spread.24Avoiding Gatherings Than 10 PeopleOn March 29, 2020, avoiding Most discourage “mass gatherings” stipulating threshold number. One reason avoid mass difficulty maintaining adequate situations. estimate size event would require knowing prevalence illness target population. illustration, if 5%, gathering 40% probability attendees infected. If 15% instead, rise 80%. Given widespread testing most go undiagnosed because minimal symptoms, unknown. selecting number cap arbitrary. scientifically definable number, concept will proportional crowd. standpoint, bigger better. also emphasize factors influence spreading, notably density crowd time.Evidence crowding events limited accounts consensus effectiveness particular intervention.25 There prospective trials avoidance. best comes studies.26 well-known example effect banning places reducing death 1918.5Quarantine Exposed Individuals 14 DaysQuarantine defined imposed restriction others overtly others.1 judged weak, considered effective burden ability delaying peak epidemic.26 Studies coronavirus outbreaks SARS MERS (Middle East syndrome) consistently found beneficial quarantine, instituted measures.27–29 benefit although certainty available simulation modeling.29Major concordantly 14-day period determined specifics incubation development symptoms. pooled 181 reported median 5.1 days 97.5% developing symptoms 11.5 days.30 101 out every 10,000 develop after quarantine. Documented periods reported.31Based recently reasonable, recognizing ?1% until should extended days, particularly contacts immunocompromised high-risk On hand, adverse consequences placing working services.32Duration Handwashing Should Be Least 20 SecondsIn measures, personal universally endorse hygiene part their controlling COVID-19.6–8 multiple effectively remove bacteria hands foodborne illneses.33,34 indicate time spent washing falls duration.35 restrooms, mean 5 seconds. Even hospital settings, times fall durations approximately seconds.The varies However, all ?20 recognizes that, “determining optimal difficult impacts altering done.”36 15 seconds removes significantly germs shorter periods.33,37–39 healthy volunteers 20-second lather 0.5 log bacterial colony-forming units 5-second wash times.38 noted analyzed specifically COVID-19. Nevertheless, supports recommendation frequent least seconds.ConclusionReflecting scant scientific offered differ specific handwashing. contest presumption research needed resolve areas uncertainty. exact thresholds value individual unclear, data population-level, observational, support mitigation pandemic. By “flattening curve,” delay population, prevent resources becoming overtaxed, buy therapies. begun reopen lax, resurgence regions unwelcome interventions.AcknowledgmentsThe authors wish thank Ms. Denise Gidaro assistance preparation formatting manuscript. grateful unrestricted philanthropic grants Stanley Arlene Ginsburg Family Foundation Aileen K. Brian Roberts Foundation.Author Disclosure StatementThe declare conflicts interests.Funding InformationThe Drs. Savage Fischman Foundation. foundations involvement knowledge work.References1. Organization. Non-pharmaceutical impact epidemic influenza. Geneva: Organization, 2019. Google Scholar2. Li R, Pei S, Chen B, et al. 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ScholarFiguresReferencesRelatedDetails Volume 24Issue 3Jun 2021 Information© 2021; Published Mary Liebert, Inc.To cite article:Michael Mamas.Social Pandemic.Population Management.Jun 2021.299-303.http://doi.org/10.1089/pop.2020.0180creative commons licensePublished Volume: 24 Issue 3: June 8, 2021Online Ahead Print:September 2, 2020KeywordsCOVID-19 pandemicsocial distancingnonpharmaceutical interventionspublic guidelinesOpen accessThis Open Access article distributed terms Creative License [CC-BY] ( http://creativecommons.org/licenses/by/4.0), permits distribution, reproduction any medium, provided original properly cited.PDF download