Sustained Management of COVID-19: Doing More of What Works to Control Future Surges.

Increasing COVID-19 infection rates and the prospect of a significant fall surge are concerning to state and territorial public health leaders. Health officers are charged with preparing for ongoing management of the pandemic while addressing pushback against public health mitigation efforts and public sentiment that the pandemic is “over.” While hospitalizations continue to remain manageable as of June 2022, now is the time for public health officials to prepare for responses to upcoming surges of COVID-19 in tandem with other seasonal respiratory viruses such as influenza and respiratory syncytial virus. Experts have learned a great deal about effective prevention, mitigation, and management of COVID-19 over the last 2 years to help guide future efforts. Planning for future response should draw upon evidence-based prevention efforts and what has worked in the past 2 years.

A “Technical Package” of Effective Public Health Approaches to Managing COVID-19

This article summarizes approaches to preventing COVID-19 infection with an eye toward sustained management of COVID-19 in the fall of 2022 and beyond. We bundle these interventions into a “technical package,” a set of recommendations to the field to guide future public health responses to COVID-19. ASTHO technical packages are based on evidence-based interventions, promising practices, subject matter expert recommendations, and—where it exists—consensus from the field. Technical packages are not intended to be comprehensive but instead help prioritize efforts toward what works to address a particular problem, such as COVID-19, and establish a focused and proactive approach to technical assistance. The ASTHO technical package to support the sustained management of COVID-19 comprises 5 major categories, described as follows, with additional details outlined in the Table.

Increase immunization rates and capacity: Vaccines, both the primary series and booster dose, are critical tools to prevent severe illness from COVID-19 infection. Engaging health care providers, who are often the trusted source of information for individuals who have questions about vaccines or who may be hesitant, is an established evidence-based practice for addressing vaccine hesitancy. Expanded availability of vaccine in health care settings will be particularly important in pediatric COVID-19 vaccination. National data already indicate a preference for pediatric COVID-19 vaccination in medical settings,1 and vaccination can serve as an important opportunity for families to reengage their children in well childcare following the pandemic shutdowns. States can identify and address financial, access, and administrative barriers to participation in the COVID-19 vaccination program. They can also work with their state Immunization Information Systems (IIS) to review immunization data use and exchange policies to identify potential barriers and leverage the IIS reminder and recall function so that medical practices can easily identify and outreach to patients who are not fully vaccinated.

Identify and address COVID-19 health disparities: Population-based data are foundational to public health practice. Having the capability to identify disparities in case numbers, hospitalizations, death, vaccination status, and access to therapeutics by race, ethnicity, and urban/rural differences is essential to guide redistribution of interventions and services, target outreach, and inform public policy. Health equity cannot be realistically addressed without accurate and complete race and ethnicity data in all public health data sets. States can consider engaging health information exchanges in matching public health data sets with vital statistics and other data sources; incentivize medical providers and commercial laboratories to provide more complete race and ethnicity data; and expand the use of the social vulnerability index to identify vulnerable rural populations at a greatest risk of poor COVID-19 outcomes.

Expand the capacity and scope of the public health workforce: Response to the COVID-19 pandemic should include health agency efforts to sustain their investments to support, expand, and increase the effectiveness of the public health workforce. Investment in community-based public health workers (eg, community health workers [CHWs], promotoras, peer recovery coaches) has been widely recognized as an evidence-based approach to improving individual and community health and addressing health disparities.2 Their ability to build trust and relationships in underserved communities is essential to successful public health work in the future. Community-based public health workers have a deep understanding of their communities through lived experience, which makes them uniquely qualified to address social and behavioral determinants of health. Early contact tracing needs led to widespread use of CHWs through contractual and temporary hiring. This capacity could be sustained and redirected to other aspects of public health by standardizing CHW job descriptions, salary ranges, and supervision structures in state/local human resources systems and by partnering with local and national community-based organizations. More broadly, states can conduct workforce surveys and update workforce policies, including sick leave policies.

Prepare the public to make risk-based decisions: The availability of highly effective COVID-19 vaccinations has dramatically reduced the risk of severe disease and death, and effective therapeutic agents are widely available for individuals at high risk who can be quickly treated after confirmed infection. Home COVID-19 testing now provides an accessible and convenient mechanism for early diagnosis. The use of these important assets in the COVID-19 response must be communicated to the public through succinct messaging guided by audience testing. Variation in community transmission, and the risk associated with certain behaviors, should be made clear so that individuals can make their own decisions about avoiding gatherings, social distancing, or wearing masks. In addition, new social norms of staying home when sick or wearing a mask when exposed should be reinforced with expanded workforce sick leave benefits and periodic, localized use of testing, contact tracing, and mask wearing requirements during disease surges.

Implement environmental interventions in schools, workplaces, and other congregate indoor settings: Infectious diseases such as COVID-19 can spread through the inhalation of airborne particles and aerosols. Environmental interventions to reduce COVID-19 spread in confined workplaces such as meat and poultry processing facilities were highly successful early in the pandemic.3 There is broad consensus that improving indoor air quality in school buildings can reduce the risk of COVID-19 spread among students and teachers.4 Many school systems are now working to upgrade their HVAC systems, and similar approaches could be considered in long-term care facilities. Wastewater surveillance is an emerging community surveillance system that could be particularly useful in self-contained water treatment system settings such as large international airports and correctional facilities.

Conclusion

State and territorial health officials have been tasked with addressing many challenges throughout the COVID-19 response. The considerations listed earlier are not comprehensive. A wide range of other strategies and approaches, such as the use of pharmacies for adult COVID-19 vaccination, have clearly been effective but have not been formally researched or evaluated. Several public health policy interventions have had unintended consequences, and external factors such as worldwide shortages of personal protective equipment and testing materials were never anticipated. The approaches in this technical package provide tangible, evidence-based actions for states and territories to consider as they plan for sustained and improved management of COVID-19 for fall 2022 and beyond.

TABLE

ASTHO Technical Package on COVID-19 Sustained Management Strategies

Objective	Potential Indicators	Mechanisms	Levels of Influence
Increase immunization rates and capacity	Provider enrollment in COVID-19 vaccine program Practices with ability to link to IIS for vaccination status	Provide enrollment incentives Remove administrative burdens to enrollment Enable IIS reminder and recall functions	CDC State immunization managers State medical and primary care associations
Identify and address COVID-19 health disparities	State public health dashboards Completeness of data reports to CDC State and federal data quality measures and benchmarks	State disease reporting laws and requirements Data set comparisons and matching Reporting incentives and penalties Provider education Race and ethnicity definitions and standards Electronic transmission capabilities	State HIEs State Medicaid agency State FQHC associations State medical and primary care associations CDC, ONC, CMS, OMB, HRSA National public health associations (CSTE, APHL)
Expand the capacity and scope of the public health workforce	CHW job descriptions, salary ranges, supervision structures in state/local HR system State CHW registries (NACHW) State and local workforce surveys State contracts with CBOs	Retention/career ladders Evidence-based practice recommendations Workforce reorganization New funding lines and resources Redirection of existing funding Attrition planning Third party reimbursement	State HR systems State contract policies State employee health plans National associations (NACHW, APHA) CDC HHS Office of Minority Health
Prepare the public to make risk-based decisions	COVID-19 vaccination rates COVID-19 therapeutics utilization rates New state policies, including the expansion of sick leave benefits Public polling	COVID-19 community indicators Tax and other incentives for employers to expand benefits Required benefits standards for employers	CDC Employer groups
Implement environmental interventions in schools, workplaces, and other congregate and indoor settings	Infection rates in congregate settings School closures	Resources for environmental enhancements Regulatory and statutory requirements Participation in EPA clean air in buildings challenge	CDC NIOSH EPA ASHRAE

Abbreviations: APHA, American Public Health Association; APHL, Association of Public Health Laboratories; ASHRAE, American Society of Heating, Refrigerating and Air-Conditioning Engineers; CBO, community-based organization; CDC, Centers for Disease Control and Prevention; CHW, community health worker; CMS, Centers for Medicare & Medicaid Services; CSTE, Council of State and Territorial Epidemiologists; EPA, Environmental Protection Agency; FQHC, federally qualified health center; HIE, health information exchange; HR, human resources; HRSA, Health Resources and Services Administration; IIS, Immunization Information System; NACHW, National Association of Community Health Workers; NIOSH, National Institute for Occupational Safety and Health; ONC, Office of the National Coordinator for Health Information Technology; OMB, Office of Management and Budget.