Publications

This operational toolkit has been developed to help business owners who are considering reopening or expanding their operations to determine their establishments’ risk of transmission of COVID-19 and how to reduce it.

As displayed in the figure below, the Operational Toolkit consists of 3 parts: an instruction manual; a business risk worksheet; and an assessment calculator.

As some governments begin to lift strict public health measures and move into the next phase of their outbreaks of COVID-19, local, state, and federal authorities are planning for the gradual reopening of businesses and resumption of economic activity. While planning for a staged approach to business resumption must be coordinated by local, state, and federal authorities, individual organizations should start planning for how they will restart or expand their operations so that modification and mitigation measures will already be in place when work can resume and the new ”business as usual” can commence.

This operational toolkit allows business leaders to work through a 4-stage process to obtain an overall risk score for their business and to identify considerations for reducing both operational and individual level risks posed by COVID-19. The overall score represents the inherent risk of exposure to COVID-19 that may occur in a business and possible changes to daily operations and policies that can lower the inherent risk of exposure. This toolkit is intended to provide businesses with a starting point in their planning to reopen or expand their operations by identifying their risk levels for contributing to the spread of COVID-19 and providing them with a list of mitigation measures to implement that will increase the safety of their employees, clients, customers, and community. 

The 3 parts of the Operational Toolkit include:

1. An Instruction Manual (PDF)
   Instructions that explain how to complete the 4-stage Business Risk Worksheet and Assessment Calculator.
    
2. A Business Risk Worksheet (PDF)
   A 4-stage step-by-step worksheet for you to report and understand your business’s overall risk of spreading COVID-19 and how your business operations can be made safer.
    
3. An Assessment Calculator (XLSX)
   An Excel spreadsheet you will fill out to receive a calculated risk score and a modification score.

In the 2 months after the first report of 4 cases of atypical pneumonia in Wuhan, China, on December 27, 2019,¹ the cumulative number of confirmed cases of coronavirus disease 2019 (COVID-19) in the city rose to 49 122, with 2195 deaths by the end of February 2020.² On January 23, Wuhan city shut down in response to the quickly evolving epidemic. All public transportation within, to, and from the city was suspended, and residents were barred from leaving. An estimated 9 million people remained in the city after the lockdown.³ Strict social distancing measures were also implemented, including the compulsory wearing of face masks in public.

The COVID-19 (COVID) pandemic has led to unprecedented action and innovation in the US healthcare system; at the same time, it has presented extraordinary challenges and risks. Through dramatic augmentation of surge capacity, deferral of other services, and implementation of crisis standards of care, hospitals in many locations have been able to absorb the blow of the first peak of COVID cases and continue to provide lifesaving care to both COVID patients and others with life-threatening emergencies. But many communities are just beginning to experience the full force of the pandemic, and in every location, the healthcare response to COVID has come at a very dear price. Healthcare facilities have sustained huge financial losses, and healthcare workers’ health and well-being have been put at high risk. New standard operating procedures and work processes have been improvised, and many old lessons have had to be relearned.

Coronavirus disease 2019 (COVID-19) is on the verge of being declared a pandemic. As of 7 March 2020, a total of 423 cases and 19 deaths, including several non–travel-related cases, areas of sustained community transmission, and a nursing home outbreak, have been reported (). Best-case estimates suggest that COVID-19 will stress bed capacity, equipment, and health care personnel in U.S. hospitals in ways not previously experienced (). How can health systems prepare to care for a large influx of patients with this disease?

In 2015 and 2016, outbreaks of the Zika virus began occurring in the Americas and the Caribbean. Following the introduction of this new threat, the United States’ Centers for Disease Control and Prevention (CDC) issued testing guidance for the nation’s state public health laboratories. We collected and analyzed testing guidance for all fifty states and the District of Columbia for both 2017 and 2018. In both years, state testing guidance was consistent for men and non-pregnant women, but there was notable variation in guidance for pregnant women. In addition, there were changes between the two years as testing algorithms shifted toward guidance that recommended testing in more limited circumstances. States adopted large, or complete, portions of CDC testing guidance, but were not required to conform completely, 33% of states had identical guidance in 2017 and 49% in 2018. Some of these trends, such as specifying that testing be contingent on travel, or sexual contact with an individual who has recently traveled, to an area where the Zika virus was circulating, presents a potential deficiency in the United States surveillance capacity. Understanding variations in state testing guidance enables public health professionals to better understand ongoing surveillance. This analysis provides insight into the testing practices for the various states across the country. Better understanding of how states approach Zika testing, and how that testing changes over time, will increase the public health community’s ability to interpret future Zika case counts.

Coronavirus disease 2019 (COVID-19) is a respiratory infectious disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), first detected in early December 2019 in Wuhan, China. It has since spread throughout the world.

One measure of viral spread is the R0, the expected number of secondary infectious cases produced by a primary infectious case. This calculation is used to determine the potential for epidemic spread in a susceptible population. The effective reproduction number, Rt, determines the potential for epidemic spread at a specific time t under the control measures in place (Figure 1). To evaluate the effectiveness of public health interventions, the Rt should be quantified in different settings, ideally at regular and frequent intervals (eg, weekly).

Epidemic readiness and response command the disproportionate attention of health security decision-makers, planners, and practitioners, overshadowing recovery. How patients and their families, health organizations, community sectors, and entire societies recuperate from major outbreaks requires more systematic study and better translation into policy and guidance. To help remedy this neglected aspect of health emergency management, we offer a working definition for epidemic recovery and a preliminary model of post-epidemic recovery. Guiding this framework’s development are insights gleaned from the more mature study of post-disaster reconstruction and rehabilitation as well as recognition that post-outbreak recovery – which involves infectious disease, a biological hazard – presents challenges and opportunities distinct from events involving geological or meteorological hazards. Future work includes developing a consensus around characteristics of successful epidemic recovery, applying these metrics to support pre-incident planning for post-epidemic recovery, and using such a scheme to track and inform actual recovery from an epidemic.

Epidemic readiness and response command the disproportionate attention of health security decision makers, planners, and practitioners, overshadowing recovery. How patients and their families, health organizations, community sectors, and entire societies recuperate from major outbreaks requires more systematic study and better translation into policy and guidance. To help remedy this neglected aspect of health emergency management, we offer a working definition for epidemic recovery and a preliminary model of postepidemic recovery. Guiding this framework’s development are insights gleaned from the more mature study of postdisaster reconstruction and rehabilitation as well as recognition that postoutbreak recovery—which involves infectious disease, a biological hazard—presents challenges and opportunities distinct from events involving geological or meteorological hazards. Future work includes developing a consensus around characteristics of successful epidemic recovery, applying these metrics to support preincident planning for postepidemic recovery, and using such a scheme to track and inform actual recovery from an epidemic.

Long-term care facilities, including skilled nursing facilities, nursing homes, and assisted living facilities, house some of the nation’s most at-risk populations for morbidity and mortality related to COVID-19 infection. Residents of these facilities require frequent interactions with staff such as for assistance with personal care (i.e. feeding, bathing, dressing), which increases the risk for transmission of COVID-19. Additionally, residents often have underlying medical conditions that put them at increased risk for severe complications if they become infected (1).

Serology (antibody) tests for the SARS-CoV-2 virus have the potential to inform good public health decision making during the pandemic. This report describes potential uses of the tests, areas of uncertainty where additional research is needed, and examples from other countries now beginning to make use of these tests. The priority for the United States now is to make validated, accurate tests available to: (1) public health authorities, to conduct surveillance and to estimate the numbers of people previously infected. Should antibody tests be determined to correlate with immunity to the disease, they should then be made available to: (2) essential workers, with priority for healthcare workers and those who interact with vulnerable populations (eg, nursing home residents); and (3) individuals who may use them to assess their personal risk of becoming infected with SARS-CoV-2 (COVID-19 disease). These tests will be in high demand, and manufacturing should be scaled appropriately, but the first steps will be to ensure accuracy, validity, and comparability of available tests.

Recent experiences during a variety of disease outbreaks, ranging from Ebola to influenza, have underscored the potential for epidemics to have an impact on daily life, even for those who are not themselves infected.^1,2 In severe situations, epidemics or pandemics can even affect overall community functioning. For example, a rapidly expanding pandemic can result in shuttered schools, cancelled events, food insecurity, and social distrust in communities.

The global reach of infectious disease pandemics typically necessitates a similarly ubiquitous public health intervention: mass vaccination. The development and large-scale deployment of a vaccine requires substantial investment and a coalition of stakeholders to undertake research and development (including phase I to III clinical trials), manufacturing, and widespread administration. Recent efforts by national and international funders and researchers to advance the state of vaccinology for pandemics and other infectious disease emergencies have focused largely on expediting the R&D phase1. There has been comparatively less attention paid to modernizing, optimizing, and therefore accelerating other aspects of the vaccine enterprise—namely, manufacturing, distribution, and administration. The current COVID-19 pandemic plainly underscores the need to vastly accelerate mass vaccination in every phase.

Currently, there are approximately 2.3 million people detained behind bars in the U.S., including 21,142 people in Maryland state prisons and Baltimore city jails (1,2).

As evidenced by a surge of cases in jails and prisons across the country (for instance, Rikers Island Jail in NYC, Cook County Jail in Chicago, a federal prison in Louisiana, and others) and by prior infectious epidemics spreading in prisons and jails, institutions of incarceration are environments where COVID-19 is likely spread rapidly; furthermore, many incarcerated individuals have chronic health conditions and other risk factors that put them at risk for more severe disease. As of April 9, 57 COVID-19 cases have been reported by the Maryland Department of Public Safety and Correctional Services, a more than threefold increase in 5 days (3). These numbers-- which only reflect those in DPSCS custody (state prisoners and people in the Baltimore City jail system) but not local jails-- can be expected to increase as they have in other jurisdictions.

This article describes implementation considerations for Ebola-related monitoring and movement restriction policies in the United States during the 2013–2016 West Africa Ebola epidemic.

As the COVID-19 pandemic continues to progress, most jurisdictions have implemented physical distancing measures to reduce further transmission, which have contributed to reductions in numbers of new cases. As chains of transmission begin to decline, along with new COVID-19 cases, there will need to be decisions at the state level about how to transition out of strict physical distancing measures and into a phased reopening

While health-care providers have used incentives in an attempt to motivate patients to obtain vaccinations, their effect on vaccination rates has not been systematically evaluated on a large scale. In this study, we examined whether mobile applications may improve population vaccination rates through enhanced communication and incentives education. Our study is the first randomized controlled trial assessing the effect of large-scale messaging combined with individualized incentives on influenza-vaccination rates. In this trial, we delivered messages regarding influenza vaccinations to 50,286 adults, aged 18 through 65, then compared the subsequent vaccination rate, the effectiveness of the message content and the timing. Multiple rounds of messaging occurred over a seven-week period during the 2016 flu season, after which vaccination rates were observed for one week. Participants were randomly assigned to one of three messaging approaches: conspicuous (highlighting the amount of rewards to be received for obtaining a flu shot); generic (promoting vaccinations with no mention of rewards); or no-message. Evidence of vaccination obtainment was indicated by medical and pharmacy claims, augmented by patients self-reporting through the mobile wellness app during the study period. Of the people assigned to receive messaging, 23.2% obtained influenza vaccination, compared to 22.0% of people who obtained vaccination in the no-messaging control arm. This difference was statistically significant (p < 0.01). The research revealed that messaging effectiveness decreased after each successive batch sent, suggesting that most participants responsive to messaging would become activated immediately after receiving one alert. Interestingly, in this large-scale study, there were no significant differences between conspicuous incentives and generic messaging, suggesting an important area for future research.

In order to save lives, reduce COVID-19’s burden on our healthcare system, ease strict social distancing measures, and confidently make progress toward returning to work and school, the United States must implement a robust and comprehensive system to identify all COVID-19 cases and trace all close contacts of each identified case. It is estimated that each infected person can, on average, infect 2 to 3 others. This means that if 1 person spreads the virus to 3 others, that first positive case can turn into more than 59,000 cases in 10 rounds of infections.

The immediate priorities of our national efforts to address the COVID-19 epidemic are appropriately aimed at suppressing chains of transmission through community-wide measures like stay-in-place orders and at surging hospital capacity to expand our ability to care for the rising number of sick patients. At the same time that we confront the current crisis, we must plan for the future by putting in place tools to enhance our ability to conduct effective surveillance, containment, and case management. As incidence of COVID-19 declines, case-based interventions will again become an option. Building those capabilities now will enable us to move beyond the extreme and disruptive physical isolation measures in place across the United States.

This report provides a road map for navigating through the current COVID-19 pandemic in the United States. It outlines specific directions for adapting our public-health strategy as we limit the epidemic spread of COVID-19 and are able to transition to new tools and approaches to prevent further spread of the disease. We outline the steps that can be taken as epidemic transmission is brought under control in different regions. These steps can transition to tools and approaches that target those with infection rather than mitigation tactics that target entire populations in regions where transmission is widespread and not controlled. We suggest measurable milestones for identifying when we can make these transitions and start reopening America for businesses and families.