• Tom Ford, Editor

The "Yellow Phase" - What Will it Take for Us to Get There, and What Will We Find When We Do?

Updated: May 15, 2020

Monroe County spent most of the first month of the stay-at-home order as the PA County with the most cases per capita. For the last couple of weeks it's been less, but we are still in the top ten of counties -as are five of the counties in our region. (NYTimes Chart)

News Analysis

Monroe County, which for over a month had the highest per capita incidence of COVID-19 in the entire commonwealth (and is still in the top-ten), remains in the so-called red phase, along with the other northeast counties, as well as southeast Pennsylvania. So what is it going to take for Monroe to move into the yellow phase, and what will it look like when we get there?

Decision Process

The state has partnered with Carnegie Mellon University (CMU) to create a Risk-Based Decision Support Tool that enables decision makers to strike a balance between maximizing the results of our economy while minimizing public health risks. The CMU tool looks at the impacts of risk factors such as reported number of COVID cases per population of an area; ICU and medical/surgical bed capacity; population density; population over age 60; re-opening contact risk, such as the number of workers employed in a currently closed industry sector. The CMU metrics are considered along with the county’s or region’s ability to conduct testing and contact-tracing to first and foremost maintain robust public health. The Department of Health also developed testing and contact-tracing plans that inform their phase decisions and will be used in making decisions moving forward. Factors include: having enough testing available for individuals with symptoms and target populations such as those at high risk, health care personnel, and first responders, and the ability to perform robust case investigation and have in place a contact-tracing infrastructure that can quickly identify a cluster of outbreaks to issue any necessary isolation and quarantine orders. All reopening decisions follow the six standards outlined in the governor’s plan to reopen Pennsylvania. These include adhering to: • Data-driven and quantifiable criteria to drive a targeted, evidence-based, regional approach to reopening. • Clear guidance and recommendations for employers, individuals, and health care facilities and providers for assured accountability. • Adequate and available personal protective equipment and diagnostic testing. • A monitoring and surveillance program that allows the commonwealth to deploy swift actions for containment or mitigation. • Protections for vulnerable populations such as limitations on visitors to congregate care facilities and prisons. • Limitations on large gatherings unrelated to occupations. “Our goal since this pandemic was first identified in Pennsylvania has been to save lives while ensuring that the public health system does not become overwhelmed with people suffering from COVID-19,” Department of Health Secretary Dr. Rachel Levine said. “Our contact tracing and testing plans will ensure that as we begin to resume our daily activities, we can do so safely and without fear.”

Criteria for Moving from Red to Yellow

Pennsylvania’s metrics for consideration for movement into the yellow phase are based on the federal guidance issued by the Centers for Disease Control and Prevention (CDC). The initial metric, or what the CDC refers to as “gating criteria”, is a two-week reduction in new cases of known COVID-19 infections. That is met if a county, and its associated region, has a 14-day total of new cases not greater than 50 cases per 100,000 of population. For Monroe County, that figure is 85, and for the ten-county northeast region (Monroe, plus Carbon, Lehigh, Northampton, Luzerne, Lackawanna, Wyoming, Susquehanna, Wayne, and Pike), the total is 804. Why two weeks, and why 50/100,000? They are based on the science of epidemiology and the behavior of this virus. The two-week period is about the average time until recovery after a COVID positive test. So the rolling two-week total of new positives in an area will reveal the approximate number of known active COVID-19 infections in the population. The 50 cases per 100,000 of population is the epidemiological status known as the “inter-epidemic period”. That is just what it sounds like, the extent of infection in between epidemics. Having that number of infections of a highly contagious virus, particularly one that is passed when the infected person has no symptoms, remains dangerous and requires caution, Dr. Levine tells us, in order to prevent a resurgence or community spread. In Monroe County, for example, once we exceeded the critical mass of 50/100,000 cases, the numbers of infections immediately began doubling every three days, and we went to number one on the list of counties with the highest per capita infection rate, staying there for a month. The exponential growth slowed after more restrictive measures went into place, such as universal masking, reducing retail store occupancy, and the like. The risk of those cases breaking out again is what the other evaluative factors are intended to mitigate. Those other factors comprise the other metrics that are considered before a county will be moved into the yellow phase. The Department of Health will look to see if a county's hospital utilization rates are going down, so that there are plenty of beds available to handle non-COVID patients, as well as a resurgent outbreak. Currently in Monroe County, our two hospitals, St. Luke’s and Lehigh-Pocono, have seen their COVID-19 cases diminish significantly. A few weeks ago, 60-70% of the admitted patients were COVID-related, and 75% and more of their ER patients were presumptive COVID-positive. Today, those numbers are down significantly, to 20% or fewer. This decline, both hospitals say, is directly attributed to the success of the stay-at-home mitigation efforts here, which has significantly reduced the community spread of the disease. Available hospital resources is only one additional measure. The county also needs to have sufficient personal protective equipment for hospital employees and frontline workers, as well as ventilators in case there is another resurgence of patients. There also needs to be the ability to engage in contact tracing, to identify those with whom the COVID-19 patients have been in contact. There also needs to be the capacity to test those contacts, identify, and isolate the infected to prevent a resurgent outbreak. The testing capacity needs to be sufficient to test symptomatic patients, the vulnerable populations, and essential health care, first responder, and front-line workers. Moving to the yellow phase is not only about the number of patients, it's about those other factors: hospital capacity, personal protective equipment, availability of contact tracing, and robust testing capacity. All the parts have to be working to move from the “stay-at-home” red phase, to the yellow “aggressive mitigation” phase of this response to the pandemic. The decisions are also complicated by the natural interactions among counties in a region. Workers and consumers routinely move between county lines - “the virus does not respect county borders,” Governor Tom Wolf says frequently. Therefore the analysis for moving a county from red to yellow will involved the relative status of adjacent or nearby counties. Some counties have no or limited hospital facilities. Residents there will accordingly rely on the medical assets of nearby counties for care. Therefore the factors involving testing, hospital capacity, and the like, necessarily cross county lines. Other counties may have a significant number of workers who commute into other counties or states, or may have visitors come into those counties from other areas. The Poconos are a prime example of both circumstances. Necessarily subjective decisions will need to be made in consideration of those factors. On May 1, the governor announced 24 northwest and north central counties would move into the yellow phase on May 8, and on the 8th identified 13 more, mainly in the south west, to move to yellow on May 15. In each case the groups of counties in the same health regions mostly moved together, but there were exceptions based on the second group of factors. “Over the past two months, Pennsylvanians in every corner of our commonwealth have acted collectively to stop the spread of COVID-19,” Wolf said announcing the first group to re-open. “We have seen our new case numbers stabilize statewide and while we still have areas where outbreaks are occurring, we also have many areas that have few or no new cases.”

What Does the “Yellow” Phase Mean?

Once we get to the next phase, what will it look like? “Yellow means ‘caution’,” says Governor Wolf. The yellow phase is also known as “aggressive mitigation” – it is not even close to a return to normal business. “More businesses can reopen, but proper safety measures must be in place,” Wolf said, “There are fewer social restrictions, but residents should continue social distancing, wearing masks in public, and doing everything they can to prevent the spread of COVID19.”

Before looking at what would look different in a "yellow" phase economy, let's correct a popular misapprehension out there that the Wolf Administration is the source of the list of what businesses are considered essential. The actual source is the federal government, specifically the Department of Homeland Security. As most states did, Pennsylvania based its business guidance on the Essential Critical Infrastructure issued by the Department of Homeland Security Cybersecurity and Infrastructure Security Agency advisory. The ECIS was developed by the Trump Administration in a project led by Christopher Crebs, Trump's appointee to become the first Director of the newly-created Cybersecurity and Infrastructure Security Agency.

Okay, now that we have the PSA out of the way. Broadly speaking, the yellow phase will look like this: Work & Congregate Setting Restrictions • Telework Must Continue Where Feasible • Businesses with In-Person Operations Must Follow Business and Building Safety Orders • Child Care Open Complying with Guidance • Congregate Care and Prison Restrictions in Place • Schools Remain Closed for In-Person Instruction Social Restrictions • Stay at Home Order Lifted for Aggressive Mitigation • Large Gatherings of More than 25 Prohibited • In-Person Retail Allowable, Curbside and Delivery Preferable • Indoor Recreation, Health and Wellness Facilities and Personal Care Services (such as gyms, spas, hair salons, nail salons and other entities that provide massage therapy), and all Entertainment (such as casinos, theaters) Remain Closed • Restaurants and Bars Limited to Carry-Out and Delivery Only All businesses in the Yellow Phase counties not specifically mentioned as restricted from reopening may reopen if they follow the guidance. Most in-person retailers, like appliance stores, clothing stores, and sporting goods stores, will be permitted to operate, but curbside pick-up and delivery are still encouraged. Pet stores are also open to all customers under yellow phase, not just those purchasing pet supplies and those seeking veterinary treatment for pets. Customers employees and customers will still be wearing masks. Shopping malls may not reopen, although stores with their own external entrances may operate if they adhere to all of the other distancing, mitigation, and occupancy requirements. Golf courses, marinas, and gun stores were opened under red, but under yellow, they have less strict rules. Bike shops and cell-phone providers under red were only allowed to perform repairs, but under yellow, they can make in-person sales. Bail bondsmen, law offices, notary and title services, car dealerships, garden centers, dog groomers, and apartment leasing offices are open for in-person sales under yellow phase. Child-care providers are allowed to operate, but must comply with state guidelines. Businesses that were able to have employees telework, are required to continue to do so as much as feasible. All businesses will have criteria they must meet in order to remain open. Some of those rules that need to be followed are: • Businesses should conduct business with the public by appointment only, whenever possible. • If appointment-only service is not feasible, retailers should limit the number of people inside the building to no more than 50% of the total maximum occupancy. • Customers must wear masks at all times, with some exceptions for infants and those with medical conditions. • Hours will likely be modified so that there is enough time to clean and restock, including designated times for people at high risk to shop. • Customers are encouraged to use online ordering by providing delivery or pick-up option. Locations providing in-person business services should be wiping down and disinfecting surfaces as often as possible. They should also have detailed plans about what to do in case they discover that an employee or customer has become infected with coronavirus. Hotels, motels, inns, and lodging houses were allowed under red phase, but short-term vacation rentals were not. But in the yellow phase, short-term rentals are allowed, as long as they adhere to social distancing, cleaning, and gathering-limit guidelines. Residential real estate showings are permitted, but must follow mitigation guidelines of wearing masks, standing at least six-feet apart, and disinfecting surfaces. Restaurants and bars will only operate as takeout and delivery. Visits to nursing homes, congregate-care facilities, prisons, and jails are still prohibited. Gyms, spas, hair salons, nail salons, and other entities that provide massage therapy must remain closed because they cannot perform services without maintaining intimate contact. Entertainment venues like casinos and theaters also must remain closed. No sporting events! Some PLCB liquor stores will open for limited in-person sales. The gathering limit for counties moved into the yellow phase is raised from ten persons to 25, but social distancing must be maintained. How long until Monroe gets into the yellow phase? No one can say, the governor and secretary of health have repeatedly denied that there was any timeline, target date, or schedule – “The virus determines the timeline,” the governor says. And, once in the yellow phase, what will it take to move into the green phase? We don’t know. “We haven’t decided that yet, because we aren’t there,” said Secretary of Health, Dr, Rachel Levine. Frustrating? You bet. “But, the frustration has to be directed at the real enemy here, the virus,” Wolf said. "It’s not the regulation, and anything we do to bring people together, whether it’s employees or customers, or both, we’re making it easier for that virus to actually attack and infect people, and we’re jeopardizing their health.” “Ultimately that’s what our individual decisions have to come down to. In the end, it’s not about regulations. It’s not about what you decided or what you’d like to do. I would like to be open all across Pennsylvania, I would like to go back to where we were in January. This virus is standing between us, and that preferred outcome. So anything we do that jeopardizes anybody’s life, that makes it easier for that virus to spread. That’s not going to be helpful.”

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