Phasing in the Reopening of the Economy

Pandemic Status and Key Statistics (as of April 30, 2020)

• Global Impact: Total reported infections reached 3.2 million with 228,000 fatalities worldwide.
• United States Impact: Infections exceeded 1 million; total fatalities reached 61,600.
• State Disparities: New York recorded 10 times the fatality rate of California despite having roughly half the population.
• Dispersion Drivers: Differences between states are attributed to population density, socioeconomic factors, occupational exposure, and the necessity of mass transit in urban centers.

Epidemiological Metrics and Uncertainties

• Case Fatality Rate (CFR): Current estimates (approx. 2%+) are likely overestimated due to insufficient testing and selection bias favoring severely ill patients.
• True CFR Potential: Studies in Germany, Iceland, and New York State (suggesting ~20% prevalence in NYC) indicate the true CFR may be closer to 1% or lower, though methodological inconsistencies remain.
• Reproduction Number (R): Physical distancing successfully reduced R to below 1 in most U.S. regions; only seven states (including Wyoming at 1.11) currently show R > 1.
• Herd Immunity Threshold: Experts estimate 65% to 75% of the population requires immunity to stop transmission, a level not yet reached even in high-prevalence areas like New York.

Therapeutic Developments

• Baricitinib: The NIH study indicated a median recovery time of 11 days for patients receiving the drug versus 15 days for the control group, with an 8% survival improvement, potentially establishing it as the new standard of care for advanced disease.
• Chloroquine/Hydroxychloroquine: Experts advise against use outside of randomized controlled trials due to toxicity risks and a narrow therapeutic index.
• Regeneron (Kevzara): A study in serious COVID cases was stopped early due to lack of efficacy, though it continues to be studied in critically ill patients.
• Monoclinical Antibodies: Regeneron and Vir Biotechnology are developing precise antibody cocktails; clinical deployment is expected by June 2020.
• Cytokine Storm Treatments: Multiple candidates (e.g., baricitinib) are being evaluated to suppress the immune response in severe cases.

Vaccine Landscape

• Moderna: An mRNA vaccine has advanced to Phase 2/3 trials; efficacy depends on establishing protective antibody titers.
• Oxford/Johnson & Johnson: Both use adenovirus vector technology; Oxford has partnered with India's Serum Institute for mass manufacturing.
• BCG Vaccine: Being tested in a multi-site study (lead: Texas A&M) to assess if it diminishes disease severity via innate immune stimulation, with results expected by year-end.
• Historical Context: Unlike MERS and SARS, the global commitment to financing and prioritizing COVID-19 vaccine development has accelerated the timeline.

Economic Reopening Strategy and Triggers

• Current State Status: Most states reopening (e.g., Texas, Georgia) have not met the White House criteria of a sustained 14-day reduction in cases; some, like Georgia, are seeing baseline increases.
• Phase 1 to 2 Transition: Requires sustained case reduction, sufficient hospital capacity, and robust testing/tracing capabilities; currently, many states are proceeding with Phase 1 without fully meeting these triggers.
• Hospital Capacity: Most reopening states possess excess ICU and hospital capacity, though New York and New Jersey have historically approached crisis levels.
• Testing Requirements: Current capacity (~230,000 daily tests) is below the estimated 750,000 tests/week needed for effective containment; a goal of 3–5 million weekly tests is advocated.
• Contact Tracing: Significant gaps remain in tracing capacity; states like Massachusetts and Texas are scaling programs, supported by apps from Google/Apple and the Commons Project.
• Reopening Risks: Lifting restrictions is expected to cause temporary case increases; however, partial reopening (e.g., limiting restaurant capacity to 20-25%) aims to manage this.
• Fall Predictions: Experts anticipate potential waves in fall/winter due to weather and returning to closer proximity, though treatments may mitigate severity to "bad flu season" levels.

Serology and Testing Capabilities

• Mount Sinai Test: Developed rapidly using the viral sequence released in January; demonstrates high specificity (near 100%) and sensitivity via a two-step ELISA process.
• Immunity Questions: While antibodies neutralize the virus, the duration of protection against reinfection is currently unknown; historical data on common cold coronaviruses suggests 1–3 years of protection.
• Test Reliability: Many commercial "lateral flow" tests suffer from low specificity, leading to false positives that incorrectly imply immunity.
• Distribution: Mount Sinai is commercializing the ELISA test and expanding local hospital capacity; broader distribution is expected "relatively soon."

Regional Specifics and Future Scenarios

• New York vs. California: New York's earlier shelter-in-place timing and high density/mass transit reliance contributed to higher initial case loads; reopening will be slower and more phased.
• University Reopening: Education is a high priority; high schools may reopen first, while universities may adopt phased approaches (labs first, virtual lectures for at-risk faculty) with delayed international travel.
• Potential for Re-imposition: Governors are preparing "triggers" (increased hospitalizations/cases) to re-impose restrictions if reopening leads to uncontrolled surges.
• Inevitability of Waves: Experts predict multiple peaks and troughs geographically until herd immunity is achieved via vaccination, with public health measures aimed at flattening the height of these peaks.