It’s been three years since the Covid-19 pandemic began, and yet many aspects of how to best respond to a novel virus remain unsettled or fiercely debated.
The next currently unknown virus that could cause a pandemic — what the World Health Organization calls “Disease X” — may be different from Covid, requiring a different set of tools and a different level of response. As Dr. Tom Inglesby, director of the Johns Hopkins Center for Health Security, outlines in a guest essay, public health leaders sometimes participate in simulations where they are asked to make decisions based on limited information about Disease X, as they would at the beginning of any pandemic.
We asked a group of experts to take part in a scaled-down Disease X simulation to show readers the diversity in views on how to best respond to pandemic threats — quickly, with little detail, as they would likely have to in a real-world situation. We gave the experts a few parameters, and asked them to briefly address specific questions they may be asked by local leaders if such a virus were to emerge and spread in their communities.
As you’ll see, not everyone agrees. We hope to show that experts with policy-making experience and similar goals can come to different conclusions and advise different strategies.
Parameters: A respiratory virus starts spreading tomorrow in the United States. It appears more transmissible and more deadly than SARS-CoV-2, the virus that causes Covid-19, and it is equally risky for children and adults, based on the rapid spread and number of deaths in another country. There’s no available vaccine, though one is under investigation. There are only 10 reported cases in the United States, but five are in the jurisdiction you are advising. This is all the information available.
Should schools close?
Yes, but only briefly. Prolonged school closures during the Covid-19 pandemic caused substantial harms that will likely be felt for decades.
Dr. Jay Varma, former Covid-19 adviser to Mayor Bill de Blasio of New York
Why, then, would anyone argue in favor of closure? In this scenario, I believe jurisdictions should close in-person school and child care for a brief, well-defined period to strengthen respiratory virus protection measures and accommodate students who choose remote learning and employees who are most vulnerable.
With a new, potentially lethal respiratory virus circulating, school closures have two theoretical benefits: reduce illness in children and adults present in schools, and reduce community spread. The harms include impaired education and social and emotional development; physical and mental health issues; and loss of economic activity for parents.
During a brief closure for this new pandemic, states should use the billions of unspent Covid-19 funds and recent Covid-19 systems and contracts to immediately improve indoor air ventilation and disinfection, enlist families to build do-it-yourself air purifiers, supply N95 or KN95 masks in all sizes, contract with local health organizations to provide on-site testing services, and develop alternative staffing and remote learning plans for personnel and children who decline to come to school.
This latter point is critical: Many staff members and parents fear for their and their children’s safety during epidemics, and jurisdictions must accommodate their needs, which may require suspending in-person school. But policymakers should publicly commit to reopening no later than four weeks after closure. For those localities that choose not to close, federal officials should make high-quality masks available through a mail-order system and fund remote learning options that meet the home-schooling requirements in multiple states.
No, at least not yet. The decision to close schools must be based on the best current understanding of risks and benefits.
Dr. Tom Frieden, former director of the Centers for Disease Control and Prevention
Pre-Covid modeling of school closures in an influenza pandemic indicated that benefits might only be minimal and the harms substantial.
Experience during Covid makes the harms of school closures even more apparent. Children fell far behind in learning, creating a gap that will reverberate for years, as well as in their social and emotional development. Children lost opportunities for healthy nutrition, physical activity, social support and more. Parents and caregivers were less able to work efficiently. And these costs fell disproportionately on those least able to afford it – families living in or near poverty or who are otherwise disconnected or disenfranchised.
For all these costs, the benefits of closing schools may be minimal. Masking, ventilation, protocols to keep ill children home and other measures minimize spread in schools. Because children often congregate in less-controlled environments when not in school (social events, contact sports, other indoor environments), the reduction in virus transmission may be relatively small.
It might become necessary to temporarily close schools in the event of widespread closures, or if schools have difficulty operating safely due to illness among a large proportion of staff, or if a school is caring for medically frail children or, in a last resort, because the virus is spreading widely and with high severity in schools. But the bar to close schools needs to be high – much higher than was used during Covid. If schools are closed, there should be frequent reassessments with the goal of reopening as soon as possible.
Should there be a mask mandate?
Yes, it will help. The virus is most likely already spreading undetected in our community.
Dr. Nicole Lurie, former assistant secretary for preparedness and response at the U.S. Department of Health and Human Services
With the virus spreading rapidly in another country, and with five cases found in our area, we can be confident it’s here. The spread will probably now be rapid and exponential, and soon it will be a major killer.
Our first job is to save lives and slow the spread, and my advice to a city official is that a temporary mask mandate will help with that until we know more about this virus and a vaccine or other therapy becomes available. The sooner we act, the better are our chances to avert needless deaths, prevent the health care system from crashing and limit economic damage.
The simple truth is that high-quality masks are effective in slowing the spread of respiratory viruses. During the early days of the Covid pandemic, countries that quickly put mask mandates in place had far fewer cases and deaths than those that did not. Studies also show that communities with mask mandates saw fewer infections than those without them.
Why a mandate? Because getting a virus under control is much harder unless everyone wears one. Wearing a mask might feel a little uncomfortable, but it’s far better than losing a loved one.
A mandate is more likely to be accepted if city officials already have community trust. This requires listening, explaining and maintaining honest, clear communication with the public and community leaders, and aggressively combating disinformation. Public trust is key to reducing infection and death. Doing the right thing is not always easy, but it will save lives.
No, this isn’t the time. There are other effective interventions to focus on first.
Dr. Anders Tegnell, the former state epidemiologist in Sweden
This is most likely not the time to mandate masks, as there are other options. People should avoid crowded indoor spaces and stay home if they are feeling sick. People should work from home as much as possible. Big events should be canceled, and the number of diners allowed in restaurants should be restricted. These are all interventions that are likely to lower the spread of disease.
Contact tracing needs to start now, and testing should be made available when it can be. In health care settings, masks should be used. Masks and other hygiene measures should be especially emphasized in elderly care.
Studying this disease and learning more about it and what interventions might be most effective should begin right away. That way all measures can be tailored to the situation at hand.
Sweden did not issue a mask mandate during the Covid pandemic, though masks were encouraged at various points. The few high-quality studies done on mask wearing in public show, in my view and that of other researchers, a limited effect. It should not be considered the first or most important intervention to control spread. However, careful monitoring is essential to tailor interventions to the new threat.
Should there be an international travel ban?
Yes, if done properly. Travel bans can be an effective public health tool.
Dr. Jerome Adams, the 20th U.S. surgeon general
Travel restrictions have been used throughout history to slow infectious disease spread. They can’t keep diseases out of a region indefinitely, but they can buy time while the authorities learn more about a disease and its spread, and deploy additional surveillance, containment and treatment measures.
If you know, for instance, that there are higher levels of a virus detected (via testing or appearance of symptoms) in one place versus another, having a travel restriction can decelerate the inevitable diffusion of disease. Such delays can save resources, and lives. We saw this in 2020 when early travel restrictions helped prevent health institutions in the United States from being overwhelmed to the extent of those in countries like Italy.
However, it is a fallacy to believe travel restrictions alone will keep us safe in a world of global mobility and difficult-to-detect viruses, particularly ones that spread asymptomatically. Further, travel bans done haphazardly can unfairly discriminate and impose heavy economic costs.
To be most effective, travel restrictions should be appropriately timed and targeted, and must be coupled with additional measures. We met some of those criteria with Covid-19 but failed on too many others. Just as is the case with other pandemic response tools, our past suboptimal use doesn’t mean the tool itself was ineffective, or that we shouldn’t consider a pause on travel when future threats arise. Our goal should be to make better and smarter use of travel restrictions, not to do away with them altogether.
No, the impact will be low. Travel bans have rarely stopped the spread of new pathogens.
Dr. Jennifer B. Nuzzo, director of the Pandemic Center at Brown University School of Public Health
At best, they may temporarily slow the arrival of pathogens, but their impact depends on what comes next.
In 2020, a handful of countries, like New Zealand, used strict travel restrictions to buy time to bolster their national testing and contract tracing capacities against Covid. But too often travel restrictions replace a full domestic response.
To stop or meaningfully slow the spread of a pathogen, travel bans must be imposed early, with good knowledge of where a pathogen is spreading. But national surveillance capabilities tend to show us cases only in the countries looking hardest for infection. When the United States restricted travel from China at the end of February 2020, the coronavirus had probably already been spreading stateside for weeks. New York’s deadly first wave of cases was later linked to travel from Europe. Restrictions also didn’t prevent a large Omicron wave in the United States.
Instead, travel bans can create a chilling effect on other countries’ willingness to diagnose and report cases. It also hampered the movement of critical supplies to the same laboratories upon which the world depended for important information about the virus.
Instead of stopping travel, we should focus on making travel safer. Once we have a diagnostic test, we should set up temporary testing at airports. We should also expand our surveillance to include wastewater from planes to track pathogens and genetic variants.
If a safe and effective vaccine becomes available, should it be mandated?
Possibly, even though they’re unpopular. Mandates can be helpful in a pandemic.
Wendy Parmet, director of the Center for Health Policy and Law at Northeastern
Laws that require individuals to be vaccinated to work or go to school do limit individual autonomy and clash with some religious beliefs. They can also deepen distrust of public health. Still, for almost 200 years, mandates have proven to be an effective public health tool that should be considered during a pandemic.
The reasons for mandates are simple. People who forgo vaccination may be more likely to infect others, including those who cannot be vaccinated or for whom vaccines will not work due to immune impairments. During an outbreak, vaccine rejection can also strain the health care system.
In an ideal world, governments could counter the problem of low vaccination rates by increasing public awareness of the benefits and safety of vaccines and ensuring that vaccines are easily accessible. Unfortunately, such efforts often fall short, especially in the face of zealous vaccination opponents, rampant misinformation, and a highly polarized environment.
Well-devised mandates can sometimes help overcome such resistance, nudging those who are not adamantly opposed to vaccines to get vaccinated. Indeed, numerous studies have shown that mandates for schoolchildren and health care workers improve their vaccination rates.
In all cases, health officials should weigh the benefits and risks of mandates, including the risk of a backlash. Officials must also ensure that the evidence strongly demonstrates the vaccine’s safety and efficacy, that the reasons for a mandate are well explained, and that the mandate is enforced equitably. Everyone must also have the economic and social means for complying. Whether those criteria are met for any given vaccine mandate can be debated. What is certain is that a pandemic is not the time to take mandates off the table.
Not without exemptions. Mandates work, but they come with side effects.
Dr. Saad Omer, director of the Yale Institute for Global Health
The effectiveness of vaccine mandates depends on how they are carried out and on exemptions allowed from these requirements.
Over the last couple of decades, my colleagues and I have conducted studies to answer the question: What mandates are optimal to achieve high vaccination rates while ensuring vaccine requirements garner broad support? Much of our data comes from school-based mandates, but our analysis is relevant to other types of vaccine mandates as well.
Our findings suggest that vaccine mandates work, and that mandates that are too easy to opt out of are less effective. However, if there are no exemptions, or if it is too hard to get one, people find ways to avoid vaccine requirements. In the case of school-based mandates, many people may home-school their children or simply ignore vaccine mandates in schools that are lax about enforcing them.
A middle-of-the-road approach to vaccine mandates is most effective and sustainable. First, medical as well as religious or philosophical exemptions should be allowed. Physician counseling can be required for those who file for exemptions – this approach was effective in Washington State for reducing childhood vaccine refusal. Experience from U.S. colleges during the Covid-19 pandemic suggests that more frequent testing for the unvaccinated is also associated with high vaccination rates without significant backlash from students (or their parents).
Jay Varma is a professor of population health sciences at Weill Cornell Medicine and the director of Cornell Center for Pandemic Prevention and Response. Tom Frieden is the president and chief executive of Resolve to Save Lives and a former director of the C.D.C. Nicole Lurie is the executive director of preparedness and response at the Coalition for Epidemic Preparedness Innovations. Anders Tegnell is the former state epidemiologist in Sweden and former head of the department of public health reporting at the Public Health Agency of Sweden, where he is now an adviser. Jennifer Nuzzo is the director of the Pandemic Center at the Brown University School of Public Health and a senior fellow for global health at the Council on Foreign Relations. Jerome Adams is the executive director of the Health Equity Initiatives program at Purdue and a former U.S. surgeon general and Indiana state health commissioner. Saad Omer is director of the Yale Institute for Global Health. Wendy Parmet is a professor of law and director of the Center for Health Policy and Law at Northeastern University.