The State of California unveiled today its long-promised plan for dealing with the Covid crisis going forward. “We learn more about how to live with Covid-19,” reads the new plan and “California must support the ongoing ability of our state to adapt during the coming months and years.”
The state’s top health official repeatedly promised a “smarter” response which, in at least one way it has delivered. The plan is not, however, simpler. (There was a promise to at some point publish a “Smarter Covid Response ABCs” guide as an “easy way for the average Californian to stay up-to-date on guidance.”)
The topline of the new model is the flexibility to respond to future variants and outbreaks even as the state loosens many restrictions that have become unpopular. As the state’s Director of Health and Human Services Dr. Mark Ghaly said on a call with reporters, it’s less about predicting the future than being ready for it.
“Public health, after the suppression phase, is about containment,” he said.
Ghaly introduced the new framework, which he said is captured in the snappy acronym “S.M.A.R.T.E.R.” Each letter comes with a once sentence summary, on which Ghaly elaborated.
S– Stands for shots. “Vaccines are the most powerful weapon against hospitalization and serious illness,” according to the plan.
M– Is for masks. “Properly worn masks with good filtration help slow the spread of Covid-19 or other respiratory viruses.” They remain a key mitigation strategy, according to Ghaly. He promised “on and off ramps” in masking requirements depending on what presents itself. “There may be a time when we all wear masks so we don’t overwhelm our health care system and businesses,” he said. “We will refine our approach.”
A–Awareness. “We will continue to stay aware of how COVID-19 is spreading, evolving variants, communicate clearly how people should protect themselves, and coordinate our state and local government response.” Surveillance and data, plus analysis and tracking are key to identifying problems going forward. Surveillance is going to be key and being able to trigger a set of responses.
R– Readiness. “Covid-19 isn’t going away and we need to be ready with the tools, resources and supplies we will need to quickly respond and keep public health and the health care system well prepared,” asserts the new plan. “We were not where we needed to be 2 years ago,” said Ghaly, “but we have accelerated our readiness faster than almost anyone else.” Going forward, “we will be ready to take on whatever Covid throws our way.”
T–Testing. “Getting the right type of tests – PCR or antigen – to where they are needed most. Testing will help California minimize the spread of Covid-19.” Promised Ghaly, “We will continue to procure and provide testing until the private sector can take over.”
E– Education. “California will continue to work to keep schools open and children safely in classrooms for in-person instruction.” Keeping schools open is a critical pillar of the framework. “Schools can be safe and continue through he worst of the up and downs,” said Ghaly. He said that in all likelihood the state will be able to set a date “in the not too distant future” where masks are strongly recommended in schools but not required.
R–Rx. “Evolving and improving treatments will become increasingly available and critical as a tool to save lives.” This piece of the plan stressed “treatments deployed effectively, efficiently and equitably.” If there is an outbreak detected, Ghaly said the state will work on “deploying testing, technology and treatment as a triple threat” to address it.
The state also set forth some “metrics of preparedness” to make sure each point of the framework is set to deal with future issues. See chart.
Beyond the acronym, however, the plan seems more complex than promised. You can read the full text here.
Some action items related to the plan include:
• The COVID-19 Assessment and Action Unit the state will monitor the data and frontline conditions in real-time to ensure California is ready to respond to new and emerging variants and changing conditions.
• Building upon a robust, regionally based waste-water surveillance and genome sequencing network to have early and rapid insights into the changing nature of the virus and early identification of variants. This network can be scaled up to support identification of future infectious diseases
• Work with external partners and the federal government to launch the first-in-the-nation impacts of Covid-19 longitudinal cohort study to look at and follow the direct and indirect impacts of Covid-19 on individuals and communities over time
• Pursue a public-private partnership with a test manufacturer to drive down the costs of at-home tests while securing a reliable and timely supply chain for California (the state already has such a partnership with a testing lab in Valencia, which it helped build)
• Take steps to ensure our health care facilities can continue to ramp up with additional staff and resources to respond to surges to minimize the strain on our health care systems. California “will be able to surge healthcare staff by 2-3 weeks,” promised Ghaly.
While stressing flexibility, the state also provides an example of how it might make use of the new plan to detect and address a local outbreak. “Imagine a California county through its wastewater surveillance system picks up a signal indicating a higher level of transmission of COVID-19 than normal,” it reads. Californians should expect six steps to be triggered, in the following progression:
1.) Sequence the circulating strain, and answer the question: “Is the circulating strain a variant we know or is it new?” If it does not match a known strain, rapidly expedite whole genome sequencing of clinical specimens in that area to identify the genotype of the circulating viral strain.
2.) If it is a new variant, within 30-45 days in partnership with the Federal Government, the state will seek to:
a. Understand if the circulating strain responds to the existing therapeutics
b. Understand if currently available tests pick up the strain reliably
c. Understand if there is immune escape from prior infection and/or vaccines
3.) Utilizing statewide stockpiles, the state will quickly deploy testing supplies to regions picking up signals of increasing transmission allowing time for local and private testing efforts to be mobilized and scaled.
4.) Deploy additional staff that have been secured through new staffing contracts for vaccine administration to regions picking up signals of increasing transmission allowing time for local and private testing efforts to be mobilized and scaled.
5.) The state will help facilitate the deployment of surge staff for facilities in impacted regions via state-coordinated staffing contracts to ensure hospitals are prepared especially in impacted communities.
6.) The state will work with local partners, health experts, community-based organizations and others to develop messaging and communication to ensure that the public is well informed “in a culturally-appropriate manner using authentic community messengers.” Also, it will work to make data available to ensure visibility and transparency.
As for what metrics officials will use to determine if action is needed, Ghaly indicated that case or hospital numbers would most likely be key, with an emphasis on one or the other dependent on the characteristics of the variant in question.
Per the plan: “If we have another highly infectious but not as virulent variant in the future, we may focus on hospital numbers to gauge whether and how the state should react. On the other hand, if the virulence is high, we may again make decisions based on case numbers,” the logic being that a more virulent variant requires more timely action and cases are among the earliest indicators of an outbreak’s prevalence.
If, on the other hand, a strain is less virulent, the state may wait to see how hospitalization numbers rise before instituting interventions such as masking or vaccination requirements. The “on and off ramps” that Ghaly mentioned in terms of implementing or lifting mitigation measures will be tied to which data set is being watched.
Said Ghaly, “At times these on and off ramps will be measured in cases and at times in hospitalizations. A less virulent virus would be measured in hospitalizations — this is the case with Omicron.”
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