Revisiting COVID-19 policies: 10 evidence-based recommendations — Halperin et al., BMC Public Health (2021)
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A review article, Revisiting COVID-19 policies: 10 evidence-based recommendations for where to go from here, by Daniel T. Halperin, Norman Hearst, Stephen Hodgins, Robert C. Bailey, Jeffrey D. Klausner, Helen Jackson, Richard G. Wamai, Mead Over, Stefan Baral, Kevin Escandón and Monica Gandhi, in BMC Public Health (2021) 21:2084. The abstract says the authors review the latest evidence on 10 key COVID-19 policy and strategic areas, including vaccine distribution, easing restrictions, reopening schools, testing policies and preparation for future pandemics. In its conclusions, the abstract states that maintaining a constant state of emergency is not viable and that a more realistic public health approach is to adjust mitigation goals to be more data-driven.
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Halperin et al. BMC Public Health (2021) 21:2084
https://doi.org/10.1186/s12889-021-12082-z
REVIEW Open Access
Revisiting COVID-19 policies: 10 evidence-
based recommendations for where to go
from here
Daniel T. Halperin1 , Norman Hearst2 , Stephen Hodgins3 , Robert C. Bailey4 , Jeffrey D. Klausner5 ,
Helen Jackson6, Richard G. Wamai7,8 , Joseph A. Ladapo9 , Mead Over10, Stefan Baral11 ,
Kevin Escandón12,13*† and Monica Gandhi14†
Abstract
Background: Strategies to control coronavirus 2019 disease (COVID-19) have often been based on preliminary and
limited data and have tended to be slow to evolve as new evidence emerges. Yet knowledge about COVID-19 has
grown exponentially, and the expanding rollout of vaccines presents further opportunity to reassess the response
to the pandemic more broadly.
Main text: We review the latest evidence concerning 10 key COVID-19 policy and strategic areas, specifically
addressing: 1) the expansion of equitable vaccine distribution, 2) the need to ease restrictions as hospitalization and
mortality rates eventually fall, 3) the advantages of emphasizing educational and harm reduction approaches over
coercive and punitive measures, 4) the need to encourage outdoor activities, 5) the imperative to reopen schools,
6) the far-reaching and long-term economic and psychosocial consequences of sustained lockdowns, 7) the
excessive focus on surface disinfection and other ineffective measures, 8) the importance of reassessing testing
policies and practices, 9) the need for increasing access to outpatient therapies and prophylactics, and 10) the
necessity to better prepare for future pandemics.
Conclusions: While remarkably effective vaccines have engendered great hope, some widely held assumptions
underlying current policy approaches call for an evidence-based reassessment. COVID-19 will require ongoing
mitigation for the foreseeable future as it transforms from a pandemic into an endemic infection, but maintaining a
constant state of emergency is not viable. A more realistic public health approach is to adjust current mitigation
goals to be more data-driven and to minimize unintended harms associated with unfocused or ineffective control
efforts. Based on the latest evidence, we therefore present recommendations for refining 10 key policy areas, and
for applying lessons learned from COVID-19 to prevent and prepare for future pandemics.
Keywords: COVID-19, SARS-CoV-2, Public health, Vaccines, Harm reduction, Policy, Outdoor transmission, School
closure, Pandemic, Pandemic preparedness, Evidence-based recommendations
* Correspondence: kevin.escandonvargas@gmail.com
†
Kevin Escandón and Monica Gandhi are co-senior authors.
12
School of Medicine, Universidad del Valle, Cali, Colombia
13
Department of Microbiology, Universidad del Valle, Grupo de Investigación
en Virus Emergentes VIREM, Cali, Colombia
Full list of author information is available at the end of the article
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Halperin et al. BMC Public Health (2021) 21:2084 Page 2 of 12
Background this study, no significant decrease in symptomatic sero-
The coronavirus disease 2019 (COVID-19) pandemic prevalence was observed in villages where cloth masks
has caused devastating loss of life and disrupted health- were promoted. Moreover, some public health interven-
care systems and daily life globally. By late October tions can be difficult or even impossible to definitely
2021, over 245 million confirmed severe acute respira- study with RCTs [7–10]. We therefore rely mainly on
tory syndrome coronavirus 2 (SARS-CoV-2) infection the best available observational data, despite limitations
cases and over 4.9 million related deaths had been re- and potential biases, to suggest refinements to current
ported globally [1]. As the international vaccination roll- approaches and policies.
out continues to expand [2], we call for a reexamination
of existing mitigation approaches to adapt to emerging 1: Accelerate vaccination rollout
evidence on effectiveness and to minimize unintended Even with the continuing emergence of viral variants,
consequences. COVID-19 vaccines have proven to be widespread vaccination remains the quickest and most
highly effective at preventing severe disease and mortal- powerful way to reduce the toll from COVID-19 and
ity and, to a lesser extent, milder symptomatic and continue returning toward a greater sense of normality.
asymptomatic cases. While vaccination has ushered in Maximizing global vaccine production and equitable dis-
great hope, the time is ripe to revisit the assumptions tribution must be the highest priority, with innovative
underlying some current interventions and to implement mechanisms of financing and licensing production as re-
more context-sensitive, evidence-based policies. Accord- quired. The wealthier countries should largely pay for
ingly, we review the available evidence regarding 10 key this ongoing effort as a humanitarian imperative as well
policy areas for which we recommend modification or as from enlightened self-interest. This could be modeled
refinement (Fig. 1). on the experience with AIDS, in which antiretroviral
One limitation of this review is the paucity of data drugs are provided to poorer countries by bilateral and
from randomized controlled trials (RCTs) to measure multilateral donors at discounted prices and/or through
the efficacy and effectiveness of COVID-19 prevention low-cost international generic production via waived
interventions. Aside from vaccines and therapeutics [3, patents [11, 12], while pharmaceutical companies con-
4], the only exceptions to date are two RCTs of masks tinue to benefit financially in higher-income countries.
[5, 6]. A trial conducted in Denmark found no statisti- Many countries have recently made encouraging prom-
cally significant difference in infection rates between the ises in this regard, including at the June 2021 G7 Sum-
group provided with and urged to wear surgical masks mit [13], but such promises will need to be kept if not
and a control group [5]. Meanwhile, a cluster RCT in exceeded.
Bangladesh found a statistically significant 9% reduction Since vaccine supplies are still not adequate to meet
in symptomatic seroprevalence in villages where surgical the global population’s needs, they must be used as stra-
masks were provided and their use promoted [6]. In tegically and efficiently as possible. Such strategies
Fig. 1 Evidence-based recommendations for 10 key COVID-19 policy and strategic areas. Figure designed by Karina Escandón
Halperin et al. BMC Public Health (2021) 21:2084 Page 3 of 12
include prioritizing vulnerable populations and health- risk settings [42, 43]. While we applaud the US and
care workers (HCWs), and delaying doses for those with other countries for having joined the World Health
previous COVID-19 until those without prior immunity Organization (WHO) COVAX Initiative, we urge high-
are vaccinated. Delaying the second dose of 2-dose vac- income countries to also unilaterally deploy their soon-
cines for longer than the interval used in clinical trials to-expire as well as other doses overseas and to join the
may increase overall public health benefit by maximizing WHO COVID-19 Technology Access Pool, which would
coverage with first doses more quickly and may also lead allow other countries to produce patented vaccines,
to greater immunogenicity [14–19]. The US Centers for thereby expanding their availability in low and middle-
Disease Control and Prevention (CDC) recommended income countries [11]. International governance of vac-
that the second dose can be given up to 6 weeks follow- cine distribution is essential to address vaccine inequity
ing the first one [20], but implementing an even longer and to maximize outcomes globally.
duration between doses, when necessary, is consistent
with a population-health perspective. Several countries, 2: Gradually ease restrictions as vaccination expands
such as Canada, have taken this approach of extending Accumulating real-world evidence is documenting the
the duration between doses. Moreover, persons known large extent to which COVID-19 vaccines reduce severe
to have been previously infected may defer vaccination disease, hospitalizations, and mortality. Although asymp-
for 6 months or perhaps even longer post-infection [21, tomatic infection and symptomatic disease were both
22], and when they get vaccinated, appear to require greatly reduced by the vaccines in the context of the
only 1 dose of a 2-dose vaccine regimen [23–26]. Alpha variant and earlier D614G mutants [18, 19, 44–
Such approaches will require careful implementation 53], more recent data during the ascendency of the Delta
and messaging to minimize the potential risk of persons variant indicate reduced effectiveness against asymptom-
not getting vaccinated in the unconfirmed belief that atic or mild infections [54–60]. However, the vaccine-
they have already been infected, or not returning for a induced protection against severe disease from the Delta
second dose in the mistaken belief that they are fully variant appears to be remarkably intact across multiple
protected by a single dose. Other challenges facing some settings, at over 90% [55, 59]. Declines in antibodies are
countries involve choosing between rapid application of expected over time following vaccination, but cellular
less effective vaccines or waiting for the availability of memory (which enhances antibody production and pro-
better ones. Generally, those approaches that offer the tects against severe disease) appears to be much more
most people some protection as quickly as pos- durable [61, 62].
sible should be followed. Furthermore, higher-income Once vaccination has been made widely and equitably
countries should refrain from distributing booster shots available and rates of hospitalization and mortality even-
more broadly or frequently than necessary (e.g., for the tually fall, it becomes untenable to expect the vaccinated
immunocompetent general population), as this appears to follow all current restrictions imposed mainly to pro-
currently unjustified both scientifically and ethically [27, tect those who decline vaccination. The same can be
28]. In late October 2021, it was estimated that globally said regarding immunity following infection. Given the
about three times as many booster shots were being rarity of reinfection [7, 22, 63] and the duration of im-
given per day compared to the total number of vaccine munity post-infection (at least 6–12 months ) [21, 63–
shots administered daily in lower-income countries [29]. 68], those with evidence of prior infection appear to be
Vaccination and other mitigation efforts must focus as immune as those who have been vaccinated [69–72].
on protecting the most vulnerable through prioritizing Mass vaccination will accelerate achieving much
the elderly, HCWs, and other essential workers. Add- greater pandemic control, allowing measures such as
itional criteria for determining which persons should be masking and physical distancing to be gradually relaxed
prioritized due to existing medical conditions must be [7]. It is critical to acknowledge the physical, psycho-
evidence-based. Cardiometabolic comorbidities such as logical, sociopolitical, and other costs of enforcing re-
diabetes, chronic obstructive pulmonary disease, hyper- strictions and to begin easing them as hospitalization
tension, and obesity are known risk factors strongly as- and death rates fall substantially, while remaining vigi-
sociated with increased COVID-19 severity and lant and ready to revisit such decisions if circumstances
mortality [30–35]. But asthma, for example, turns out change significantly.
not to be a risk factor (and is probably even partially
protective against death and other serious COVID-19 3: Emphasize education and harm reduction approaches
outcomes) [36–41]. In certain situations and particularly over coercive and punitive measures
among groups at the highest risk of disease or exposure, “Abstinence-only” approaches have not worked for AIDS
vaccination mandates can be considered, e.g., for work- or teen pregnancy prevention [73], nor have absolutist
ing in hospitals, nursing homes, prisons, or other high- approaches worked well for preventing SARS-CoV-2
Halperin et al. BMC Public Health (2021) 21:2084 Page 4 of 12
[74, 75]. Instead, prevention measures should be 5: Reopen schools now
founded on the provision of accurate information, sensi- COVID-19 has caused by far the largest disruption to
tively communicated, and informed by harm reduction learning in recent history [103]. As the pandemic has
approaches that are more effective and sustainable in the unfolded, there is mounting evidence that the harm
longer term [7, 74–76]. Harm reduction involves inform- of keeping schools closed dwarfs any public health
ing people how to assess and mitigate risk, while ac- benefits [41, 104, 105]. By early 2020, most
knowledging the real-world conditions that may lead kindergarten-to-grade 12 (K-12) schools worldwide
some persons to take calculated risks. One example of a had closed for in-person instruction, and many re-
successful mitigation campaign (prior to vaccines) is that main shuttered over a year later [104, 106–109]. As
of Japan’s 3 Cs, which generally did not shut down soci- of September 2021, based on United Nations Educa-
ety, but instead advised the public to avoid close, sus- tional, Scientific and Cultural Organization
tained interactions in crowded enclosed spaces [77]. (UNESCO) data [109], over 100 million students
Importantly, educating and motivating the public to remained affected and 18 countries still had nation-
adopt effective precautions, including vaccination, as op- wide closures. There is no good substitute for in-
posed to coercive or punitive measures (e.g., shaming, person schooling [108]. Remote learning further exac-
fines or imprisonment, and even police violence) will be erbates inequities, especially among communities with
more effective and will help alleviate pandemic response low resources, not only related to education but also
fatigue [7, 78–80]. Accordingly, any restrictions and to safety, wellbeing, social support, and nutrition
mandates, including vaccinations passports [81–83], [105, 108, 110–112].
should focus on high-risk situations and consider a Schools have not been shown to be major drivers of
number of scientific and ethical questions. Most import- SARS-CoV-2 transmission, when studied in a variety of
antly, COVID-19 measures should be formulated and settings employing a range of mitigation strategies and
reassessed based on the latest information, levels of on- intensity [106, 107, 113, 114]. However, their prolonged
going threat, and resource availability. As mentioned closure have had disastrous academic, psychosocial, and
above, vaccine mandates should be carefully focused and other harmful consequences on children, including ac-
should take into account prior SARS-CoV-2 infection cess to essential services, especially in lower-income
[22]. populations [41, 111, 115, 116]. Furthermore, contact
tracing studies worldwide have found children are less
likely to infect adults or other children, and that most
4: Encourage outdoor activities SARS-CoV-2 infections among children are mild and are
Current evidence on SARS-CoV-2 transmission dynamics contracted at home or in the community, not at school
must inform policy recommendations for mitigation strat- [106, 107, 117–119].
egies and restrictions [84]. Unfortunately, lower-risk activ- In the US state of North Carolina prior to vaccine
ities, especially those conducted in outdoor environments availability, 11 school districts (many in regions with
(e.g., parks, beaches, hiking trails, playgrounds), have often high SARS-CoV-2 incidence) implemented in-person in-
been discouraged or even prohibited [85–90]. The risk of struction accompanied by mitigation plans, for > 90,000
SARS-CoV-2 transmission outdoors is vastly lower than children over 9 weeks [117]. Across the 11 school dis-
indoors, with most studies finding the proportion of new tricts, there were 773 community-acquired SARS-CoV-2
cases attributable to outdoor exposure to be < 1% [7, 42, infections documented by reverse transcriptase-
91–94]. Policies should reflect this enormous difference in polymerase chain reaction (RT-PCR) testing, of which
risk, including allowing access to outdoor spaces even dur- only 32 were identified as secondary cases, with no cases
ing periods of severe restrictions and reserving mask man- of within-school transmission from children to teachers
dates for indoor (and very crowded outdoor) situations or other adults. Among 17 US schools in rural Wiscon-
[7], as recommended by the WHO and CDC [95–97]. sin also conducting in-person learning, with a range of
Strongly encouraging outdoor activities and including nu- precautions, SARS-CoV-2 incidence among students,
ance in public health recommendations (such as discour- teachers, and other staff members was lower than in the
aging outdoor gatherings from leading to crowded indoor surrounding communities overall [118]. During 13 weeks
situations) is more consistent with the previously dis- in late 2020, 191 cases were identified among students
cussed harm reduction-based approaches [7, 98]. When and staff, of which only 7 (3.7%) cases (all among stu-
weather or other factors preclude holding activities out- dents) were traced to in-school transmission. In Sweden,
doors, windows should be kept open whenever possible, where schools generally remained open (and masks have
including in shared vehicles [99], and air ventilation (at not been required) [120, 121], deaths of children aged
least 4 air exchanges per hour) should be ensured to re- 1–16 years were statistically similar in the 4 months be-
duce the risk of transmission [100–102]. fore versus after COVID-19 arrived, and intensive care
Halperin et al. BMC Public Health (2021) 21:2084 Page 5 of 12
unit admission rates for teachers were comparable to disadvantaged and vulnerable populations. Other conse-
those for other occupations [122]. Many other investiga- quences include alarming increases in mental health
tions, such as one among children aged 0 to 19 years in problems (e.g., depression, anxiety, and social isolation),
childcare facilities and schools in Baden-Württemberg, drug overdose, domestic violence, child abuse, weight
Germany, after the reopening of schools in May 2020, gain, abuse by law enforcement in some places, and dis-
have also suggested that child-to-child transmission in continuation of non-COVID-19 clinical services and pre-
school settings is uncommon [123]. To the extent that vention programs [41, 78, 110, 115, 134–139]. While
in-school transmission is an issue, especially given the substantial evidence highlights the deleterious impact of
continuing emergence of highly transmissible variants sustained lockdowns, the direct impact of SARS-CoV-2
(e.g., Delta), vaccinating school staff is likely the most ef- transmission on disease outcomes, healthcare systems,
fective way to protect those at risk [124–126]. and employment, particularly in the context of huge in-
Also, after reviewing data indicating that 3 ft of phys- equity, can also produce many of the same negative ef-
ical distancing is sufficient [127], in March 2021 the fects, even in the absence of official lockdowns [140,
CDC modified their guidelines accordingly, at least for 141].
elementary school settings [128]. A large-scale CDC Tailored, context-sensitive interventions involving
study, comparing schools that mandated various inter- fewer economic, societal, and quality-of-life costs than
ventions in late 2020 with ones that did not, found that lockdowns are likely more effective and minimize
while improving ventilation and requiring teachers and harm [7]. Non-pharmaceutical interventions such as
staff members to wear masks was associated with re- physical distancing, improved ventilation, and effective
duced SARS-CoV-2 incidence in schools, mandating stu- indoor mask wearing are also more sustainable than
dents to wear masks was not [129]. Masking guidelines broad stay-at-home orders [142–146]. Although emer-
for children from major public health organizations dif- ging genetic SARS-CoV-2 variants may pose add-
fer, which has generated confusion. For instance, the itional challenges [147], the biological and
CDC currently recommends that all children over age 2 epidemiological evidence suggests that the same inter-
wear masks indoors, while the WHO mask guidance ap- ventions will work to reduce their transmission.
plies to children over age 5, with a caveat that benefits When lockdowns, isolation, or quarantine measures
from mask mandates at school may not outweigh the are mandated, economic hardship should be consid-
potential academic and psychosocial harms [130]. Des- ered and paid sick/quarantine leaves and other types
pite the inconsistent data and guidelines, student mask- of support must be provided to affected workers, es-
ing in communities where rates of hospitalization and pecially those who are most economically vulnerable
death remain high may be useful [113], if for no other [7].
reason than to help maintain the necessary consensus to
keep schools open. 7: De-emphasize excessive surface disinfection and other
The emergence of variants does not warrant closing or ineffective measures
delaying the reopening of schools unless compelling evi- The evidence is consistent that indirect contact (fomite)
dence unexpectedly indicates that a new mutation affects transmission is not a significant driver of SARS-CoV-2
children in some substantially new way [131]. Reassuring spread [148–151], as acknowledged by the CDC [152].
data from high schools [106, 107, 117, 118, 122, 123] Many routine disinfection rituals, including the ubiqui-
suggest that in-person classes also can be safely con- tous usage of alcohol-based hand sanitizers and the ex-
ducted in colleges, especially if combined with interven- cessive use of strong cleaning products, are unnecessary
tions to prevent outside-the-classroom transmission. As [41, 153]. Misuse of sanitizers, cleansers, and disinfec-
endorsed by the United Nations Children’s Fund tants has resulted in toxic reactions occasionally leading
(UNICEF) [132], no effort should be spared to keep stu- to hospitalization and even death [154–156]. Such haz-
dents in classes, and closing schools should be a measure ardous disinfection practices include washing food prod-
of last resort. ucts with bleach, applying household cleaning or
disinfectant products to bare skin, mixing bleach solu-
6: Avoid lockdowns tions with vinegar or ammonia, and intentionally or acci-
The cumulative evidence suggests that “sledge-hammer” dentally inhaling or ingesting such products [155, 156].
lockdown approaches, such as the closing of all non- Beyond being ineffective and occasionally dangerous, ex-
essential workplaces and schools, should be avoided in cessive cleaning rituals divert important resources, time,
favor of more effective, carefully targeted “scalpel” public and energy from much more useful forms of prevention
health strategies [7, 78, 133, 134]. Indiscriminate lock- [151, 153]. There are also growing concerns about the
downs have had far-reaching unintended consequences, potential longer-term impact on what many scientists
disproportionately affecting socioeconomically have warned is the looming “next pandemic,” that of
Halperin et al. BMC Public Health (2021) 21:2084 Page 6 of 12
antimicrobial resistance [157, 158]. Similarly to the mis- discovery typically lags well behind their emergence, and
placed focus on disinfection rituals, public health au- local detection often depends more on which locations
thorities and the media must do a much better job of are conducting routine genomic surveillance than on
educating the public how the coronavirus is—and is where the new variants actually originate [131].
not—typically transmitted [159, 160]. For example, fleet-
ing encounters pose minimal risk, even from more 8: Reassess testing practices and policies
transmissible variants41, 78. Experience suggests that choice of diagnostic technolo-
Another pervasive practice, temperature screening— gies should be determined by the intended use, whether
especially when using non-contact handheld cutaneous to detect infection in individuals with suspected clinical
infrared thermometers—is often inaccurate due to envir- symptoms or to identify potentially infectious individuals
onmental factors (e.g., subject-to-sensor distance, ambi- to inform isolation recommendations and conduct con-
ent temperature, humidity), operator-dependent tact tracing. RT-PCR-based assays have so far been the
performance, device variability, and feature changes in preferred method for most such purposes [170]. Rapid
target subjects [161–165]. Furthermore, fever is a poor antigen tests, which are both cheaper and faster, can lead
differentiator of the presence or absence of SARS-CoV-2 to false negatives, especially in pre-symptomatic carriers,
infection (and the use of antipyretic drugs may mask and when conducted without adequate quality control
fever). The ubiquitous use of thermometers for permit- procedures. However, if performed correctly in appropri-
ting entry to public establishments is thus ineffective. A ate populations, they may be sufficiently sensitive and
systematic review of studies regarding exit and entry specific for detecting potential infectivity [171], thus sug-
screening practices (e.g., symptom questionnaires, body gesting that antigen tests should increasingly be utilized
temperature measurement) during previous epidemics of for public health screening. Moreover, further investiga-
influenza A(H1N1), Ebola, and severe acute respiratory tion is needed regarding the extent to which positive
syndrome (SARS) found extremely low or no utility in SARS-CoV-2 RT-PCR results do not always reflect ac-
differentiating infected from uninfected [166]. For tual infectiousness [172–174], particularly among vacci-
COVID-19, similar findings have been reported, with nated or asymptomatic persons. Finally, given that
only a very small proportion of SARS-CoV-2 infection vaccination reduces symptomatic and asymptomatic
cases detected during such screening practices [167]. SARS-CoV-2 infections and that vaccinated individuals
Again, such measures divert resources and attention are likely to be less infectious if infected [175–177], test-
away from much more effective strategies to control ing and quarantine of vaccinated (or previously infected)
infection. persons following exposure to someone with suspected
Furthermore, travel-related restrictions have clearly or confirmed COVID-19 should in general only be
had a considerable impact on global trade and econ- needed if COVID-19 symptoms develop [178]. As we in-
omies as well as on other systems, including those for creasingly recognize that SARS-CoV-2 is gradually be-
international humanitarian responses [145]. Other nega- coming an endemic virus, it is vital to deemphasize
tive consequences include generating a false sense of se- identification of new cases as the key outcome metric of
curity, discouraging travelers from engaging mitigation measures and rather to assess mortality and
transparently with authorities, and potentially disincenti- hospitalization rates [179]. This is also relevant consider-
vizing open disclosure by countries during future out- ing that the vaccines were developed to reduce severe
breaks [131, 168]. Although a few countries (e.g., New and fatal outcomes from COVID-19 and not to fully pre-
Zealand, Australia, Taiwan, China), mainly island na- vent onward transmission and infection.
tions, have attempted SARS-CoV-2 elimination through
use of robust quarantine and contact tracing measures 9: Expand access to outpatient therapies and
[7, 131, 169], it makes little sense, from either an epi- prophylactics
demiological or human rights perspective, to shut inter- As with vaccines, the pandemic has presented challenges
national land borders or require a negative RT-PCR test in identifying effective therapeutics on a greatly acceler-
result for entry into countries where SARS-CoV-2 is ated timeline. Although vaccination remains the priority,
already circulating widely. Similarly, the routine use of some vaccinated individuals will still contract SARS-
quarantine upon arrival and various other entrance CoV-2, and some persons will remain unvaccinated.
screening procedures [164] are also largely ineffective. While some medications have been tentatively permitted
Such border controls are akin to confiscating matches (not without controversy) on a compassionate use basis
after the forest is already ablaze. Experience, including in a few countries, approved outpatient therapies for
lessons learned during this pandemic, suggests that im- COVID-19 have been limited in most places to intraven-
position of travel restrictions also generally fails to pre- ous monoclonal antibodies, which are cost-prohibitive in
vent the spread of new genetic variants, as their most settings globally and often pose other considerable
Halperin et al. BMC Public Health (2021) 21:2084 Page 7 of 12
challenges for widespread use. As evidence on treatment variants will soon evade current vaccines may be over-
options evolves, policymakers should prioritize quick ac- stated, as both the mRNA and adenovirus-DNA vaccines
cess to effective outpatient therapies in patients with risk encode for the entire spike protein, providing robust and
factors for severe disease and to prophylactics for unvac- complex antibody-mediated as well as T-cell immune re-
cinated persons at high risk. Assessment of previously sponses [17, 21, 185, 186]. Furthermore, vaccines can be
identified safe medications might be an efficient way to rapidly modified, if necessary, to adapt to future variants
quickly identify new therapies [180]. In addition, more [183, 184]. As previously noted, it is crucial to focus on
research is urgently needed regarding the prevalence, the key public health objectives of preventing death and
diagnosis, prognosis, and treatment options for longer- other severe disease outcomes, rather than continuing to
term (“long haul”) COVID-19 complications. use numbers of reported cases as the main metric. In
any event, maintaining a constant state of emergency
10: Prevent and prepare for future pandemics until the pandemic is over is not viable. Public health
COVID-19 is the second major respiratory viral pan- decision-making requires transparency and debate,
demic in just over a decade and the third coronavirus which are often precluded by emergency orders. A more
pandemic within 2 decades. More pandemics are likely realistic public health goal is to adjust mitigation and
in the coming years, whether from new coronaviruses treatment goals as the pandemic evolves, minimizing
and/or from other pathogens. We clearly must do every- negative outcomes including the unintended harms asso-
thing possible to prevent and be better prepared for fu- ciated with unfocused or irrelevant control efforts. The
ture pandemics and other public health emergencies foregoing suggestions for refining our current ap-
[181, 182], and must learn and apply lessons from the proaches are presented as best practices that will never-
recent experience with mitigating COVID-19. theless require continuous adjustment through
Regarding prevention, policymakers need to take pru- reassessment of the latest evidence. We offer these in
dent actions immediately to reduce the likelihood of fu- the reasonable hope of widespread vaccination helping
ture pandemics, including addressing environmental to achieve far greater control of COVID-19, and also
destruction that brings different species into closer con- that the world will be better prepared for the next
tact with humans, restricting the trafficking of animals, pandemic.
and strengthening biosecurity in laboratories that work
with potential human pathogens. Abbreviations
CDC: US Centers for Disease Control and Prevention; COVID-19: Coronavirus
Preparation for the next pandemics should include de- disease 2019; HCW: Healthcare worker; RCT: Randomized controlled trial; RT-
tailed plans by international organizations that are PCR: Reverse transcriptase-polymerase chain reaction; SARS: Severe acute
widely vetted and agreed upon. Lockdowns and quaran- respiratory syndrome; SARS-CoV-2: Severe acute respiratory syndrome
coronavirus 2; UNESCO: United Nations Educational, Scientific and Cultural
tines, when (and only if) necessary, need to be designed Organization; UNICEF: United Nations Children’s Fund; WHO: World Health
equitably and to include protection, prioritization, and Organization
compensation for those most vulnerable [7], including
the elderly, the poor, and workers in frontline and infor- Acknowledgments
We thank Karina Escandón for designing the figure for this manuscript. We
mal jobs. Effective mechanisms must also be established acknowledge Arthur Allen, Arlyne Beeche, Richard Cash, Julia Marcus,
to address equity in access to treatments and vaccines, Malcolm Potts, Josh Sharfstein, Ann Swidler, Muhammad Usman, Zeynep
prioritizing those at highest risk. We certainly must Tufekci, and David Wolfson for their useful comments. This article was first
preprinted in April 2021 at https://osf.io/nrvtf/ and was continuously
avoid another situation where public health authorities updated until publication date.
and politicians are left to fly blind and then try to clean
up the damage later. It would be a grave error to re- Authors’ contributions
spond to a new pandemic without applying lessons from DTH initially conceptualized the article and led the manuscript development.
All authors (DTH, NH, SH, RCB, JDK, HJ, RW, JAL, MO, SB, KE, and MG)
the current one. contributed to the writing of the manuscript, critically revised subsequent
versions, and agreed upon the final version of this manuscript prior to
Conclusions submission. The authors read and approved the final manuscript.
Given the high transmissibility of SARS-CoV-2, its con-
Funding
tinuing widespread circulation in some regions, and the
This article did not receive any funding or sponsorship for publication.
emergence of new viral variants [147], it is unlikely that
SARS-CoV-2 will be eradicated. Therefore, we will need Availability of data and materials
to continue focusing on mitigation strategies, particu- Not applicable.
larly vaccination [131]. Although SARS-CoV-2 genetic
variants will keep emerging, vaccines have so far largely Declarations
retained their ability to prevent fatal and other severe Ethics approval and consent to participate
COVID-19 outcomes [183, 184]. Concerns that such Not applicable.
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Medicine, University of California, San Francisco, CA, USA. 3School of Public 16. Payne RP, Longet S, Austin JA, Skelly DT, Dejnirattisai W, Adele S, et al.
Health, University of Alberta, Edmonton, AB, Canada. 4School of Public Immunogenicity of standard and extended dosing intervals of BNT162b2
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- 0918d8c40a5c6ee656ecd1c9ba9432976be6b130d812134cab0ce5756f4183f7
- Our copy
- revisiting-covid-19-policies-10-evidence-based-recommendations-for-where-to-go-from-here.pdf
- Original
- doi.org