key: cord-0790802-t64qtxsm
authors: Song, Joon Young; Peck, Kyong Ran
title: A Debate on Public Health Responses to COVID-19: Focused Protection versus Sustained Suppression
date: 2020-12-16
journal: J Korean Med Sci
DOI: 10.3346/jkms.2020.35.e433
sha: 5a3517f5b432de33620a476155dd7cc2aa387145
doc_id: 790802
cord_uid: t64qtxsm

With the coronavirus disease 2019 (COVID-19) pandemic persisting for a long time, there have been debates about the public health response strategies. We conducted a survey of adult infectious disease specialists on public health responses to COVID-19. Most responded that regulations on multi-use facilities should be maintained or strengthened, but schools should not be closed, except in cases where an outbreak occurs within the school. A slightly higher percentage of experts supported focused protection rather than sustained suppression. While the focused protection strategy might suffice in low-level epidemic situations, social distancing should be reinforced by shifting to a strategy closer to sustained suppression in the eventuality of rapid spread of outbreaks.

To minimize mortality and social harm by balancing risks and benefits until sufficient herd immunity is reached.

To control community spread of COVID-19 until effective vaccines are available.

Focused protection. Maintenance of social activities in low-risk, young age groups, and strengthened protection for high-risk groups → gradual increase in herd immunity.

Sustained suppression. Suppression of community outbreaks through reinforced social distancing until effective vaccines/therapeutics are available → secure socioeconomic safety. Supporting evidence Significant differences with age and comorbidities in the CFR of COVID-19: fatality rates were 1000-fold higher in the old and infirm than in the young. There are concerns relating to increased fatigue and economic damage when sustained suppression lasts for a long time.

COVID-19 = coronavirus disease 2019, CFR = case fatality rates. or strengthened (54.5% before and 65.4% after the meeting), and school attendance should be maintained (69.4% before and 79.5% after the meeting). Interestingly, the proportion of respondents supporting opening of schools increased after the meeting, while the proportion for sustained suppression increased. In a study using the decision analytical model to estimate the potential years of life lost because of the COVID-19 pandemic, school opening showed lower total years of life lost than school closure with a 98.1% probability. 8 The decision analytic model considered the association between school closures and reduced educational attainment and also the association between reduced educational attainment and life expectancy using publicly available data sources. School closure should be determined after giving due consideration to the opinions of pediatric infections specialists and educational experts, as well as by considering the disease prevalence/severity and educational disruption of students age-wise. A slightly higher percentage of experts supported focused protection rather than sustained suppression (66.1% vs. 33.9% and 57.7% vs. 42.3% before and after the meeting, respectively). When stratified by their experience (≥ 11 vs. < 10 years) as infectious disease experts, a higher proportion of seniors than juniors supported the focused protection strategy, although the figures were statistically insignificant (67.6% vs. 64.2%, P = 0.703 and 64.3% vs. 50.0%, P = 0.253 before and after the meeting, respectively). Although a greater number of experts preferred focused protection over sustained suppression, most of them supported a thorough contact tracing and testing strategy for COVID-19. They seemed to consider that thorough contact tracing should be done to allow the outbreak situation to be controlled while allowing social activities and subsequent infections in young adults. As for the hospital-level countermeasures, 60% of experts supported universal COVID-19 screening before admission to acute care hospitals, but this could vary depending on the level of the pandemic outbreak in the community. Considering the high risk of COVID-19related morbidity and mortality, more than 70% of the experts responded that patients and healthcare workers in long-term care facilities need periodic COVID-19 screening tests.

There are differences in the incidence of COVID-19 by country depending on the public health responses, such as school closure and social activity restrictions. However, after the COVID-19 pandemic is over, it would not be appropriate to evaluate the governmental response simply by the number of COVID-19 cases. It is compelling to identify ways to minimize public health loss while maintaining educational functions and minimizing economic damage. Rather than dividing the above-mentioned two public health response strategies (focused protection and sustained suppression) into black and white categories, both could be considered as strategic options depending on the specific situation. While the focused protection strategy might suffice in low-level epidemic situations, social distancing should be reinforced by shifting to a strategy closer to sustained suppression in the eventuality of rapid spread of outbreaks. If the COVID-19 pandemic continues for an extended period, various gray zone policies can be established while considering each country's specificity (social culture, population structure and density, international exchange activities, etc.) Moreover, it is necessary for high-risk institutions such as acute care hospitals and long-term care facilities to preemptively strengthen their levels of social distancing in the eventuality of the rapid progress of the pandemic.

Comparing SARS-CoV-2 with SARS-CoV and influenza pandemics

Covid-19 in South Korea -challenges of subclinical manifestations

Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1

Identifying airborne transmission as the dominant route for the spread of COVID-19

World Health Organization

Scientific consensus on the COVID-19 pandemic: we need to act now

The Great Barrington Declaration

Estimation of US children's educational attainment and years of life lost associated with primary school closures during the coronavirus disease 2019 pandemic

The authors have no potential conflicts of interest to disclose. 

We thank all the survey respondents and members of the Korean Society of Infectious Diseases.