Roadmap to Recovery:

A Public Health Guide
for Governors

   
   

April 22, 2020

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GOVERNORS

 

EXECUTIVE SUMMARY
The global pandemic of COVID-19 poses an
unprecedented challenge to the health and
well-being of every state and territory across
the country. In the absence of treatments and
vaccines proven to be safe and effective, states
and territories have turned to social distancing
to avoid a spike in serious illnesses and deaths
that could overwhelm the healthcare system.
While there is significant evidence that social
distancing is effective at blunting the full force
of COVID-19, these actions have come with
significant economic and social costs.
With the paramount aim of keeping individuals
and communities safe, governors are committed
to reopening states in a manner that preserves
public safety and confidence. Opening
prematurely—or opening without the tools in
place to rapidly identify and stop the spread of
the virus—could send states back into crisis
mode, push health systems past capacity, and
force states back into strict social distancing
measures. This scenario would repeat the
negative economic consequences of pandemic
response and reduce public confidence, further
deepening a recession and protracting economic
recovery.
There is substantial consensus among national
experts that significant preparation will be
required by state and national leaders to scale
up the required public health infrastructure
to limit outbreaks. States will also need to
develop plans for a careful, staged reopening
that protects the public’s health while laying
a strong foundation for long-term economic
recovery. This report synthesizes and expands
upon these expert recommendations by
outlining ten key steps and related operational
considerations for governors to guide critical
decisions in support of the public’s health and
well-being in the weeks and months ahead.

2   Roadmap to Recovery: A Public Health Guide for Governors

Building the Public Health
Infrastructure
❶ Expand testing capacity and make testing
broadly available
❷ Strengthen public health surveillance to
understand the spread of the disease and
rapidly detect outbreaks
❸ Dramatically scale capacity for isolation,
contact tracing, and quarantine
❹ Ensure the healthcare system can respond to
potential surges
❺ Protect essential workers and at-risk
populations

Creating and Executing a Plan to
Gradually Reopen the Economy
❻ Develop a strong and clear communication and
public engagement plan
❼ Create a framework for reopening
❽ Set the criteria and define the stages for
reopening
❾ Build partnerships between public and private
sectors to implement the plan
❿ Prepare to reassess and improve the plan
frequently

 INTRODUCTION
The global pandemic of COVID-19 poses an unprecedented challenge to the health and well-being of
every state and territory across the country. In the absence of treatments and vaccines proven to be
safe and effective, nations around the world have turned to social distancing to avoid a spike in serious
illnesses and deaths that could overwhelm the healthcare system. In the United States, the federal
government, states, territorial and local governments have done the same. Fortunately, there is evidence
that social distancing is effective at blunting the full force of COVID-19, saving lives and sparing the
healthcare system from worst case scenarios.
At the same time, the pandemic itself -- together with the measures taken to reduce its spread -- have
led to abrupt social and economic changes with serious consequences. More than 700,000 people have
been diagnosed with COVID-19 in the United States, and more than 40,000 have died.1School closures,
travel restrictions, and mass unemployment have altered the landscape of cities and towns, threatening
the long-term viability of many businesses, and the livelihood of many Americans. With over 22 million
Americans filing unemployment claims since social distancing measures began in March, fear of
COVID-19 is likely to further depress economic activity for as long as the infection continues to spread.2
On April 16, the White House Coronavirus Task Force released Guidelines for Opening Up America Again.
This document acknowledges the governors’ role in making locale-specific determinations, while setting
forth criteria and preparedness steps that would enable governors to take a phased approach to relaxing
social distancing measures and reopen businesses.
With the paramount aim of keeping individuals and communities safe, governors are committed
to reopening their economies in a manner that preserves public safety and confidence. Opening
prematurely—or opening without the tools in place to rapidly identify and stop the spread of the virus—
could send states back into crisis mode, push health systems past capacity, and force states back into
strict social distancing measures. This scenario would repeat the negative economic consequences
of pandemic response and reduce public confidence, further deepening a recession and protracting
economic recovery.
In recent days, the federal government as well as a number of experts, including those from American
Enterprise Institute (AEI), Center for American Progress (CAP), Johns Hopkins University (JHU), the
Duke-Margolis Center for Health Policy, Harvard Safra Center for Ethics, Vital Strategies Resolve to Save
Lives and others, have released plans or resources to support state and national leaders in developing
long-term COVID-19 responses. (See Appendix A for a side-by-side comparison of key recommendations
from these reports). There is substantial consensus among national experts that significant preparation
will be required to scale up the required public health infrastructure to limit outbreaks. States will also
need to develop plans for a careful, staged reopening that protects the public’s health while laying a
strong foundation for long-term economic recovery.
This roadmap synthesizes and expands upon these recommendations and adds key operational
considerations for governors to inform critical decisions in support of the public’s health and
well-being in the weeks and months ahead.

1
2

Johns Hopkins University. COVID-19 United States Cases by County. Retrieved from: https://coronavirus.jhu.edu/us-map (April 20, 2020).
U.S. Department of Labor. Unemployment Insurance Weekly Claims. April 16, 2020.Retrieved from: https://www.dol.gov/ui/data.pdf.

Roadmap to Recovery: A Public Health Guide for Governors   3

 RECOMMENDATIONS
From the beginning of the pandemic, governors have played a central role in leading the response to
COVID-19. With the number of infections beginning to plateau, governors now must guide their states to
reopening gradually and safely.3
A successful strategy for reopening requires states to build the public health infrastructure needed to
slow the spread of COVID-19, while developing and implementing a staged plan for bringing the economy
back to life. These steps require the full participation of the federal government, state health agencies,
other state agencies, local governments, the private sector, and the public.
Governors will make a plan for recovery possible by communicating frequently and candidly with
the public, assigning clear responsibility for key steps, building partnerships across and outside of
government, and by mobilizing the support of the private sector. Governors also clear the path for critical
actions by identifying funding, adapting regulations, and issuing emergency orders. State and territorial
health officials will be critical components of the recovery plan, as the primary lead on public health
policy and program matters, with expertise in public health emergencies such as the COVID-19 global
pandemic, natural disasters, bioterrorism events, and others.
The following 10 steps for action fall into two broad categories: building the public health infrastructure
and creating and implementing a plan to reopen the economy.

3

For purposes of this report, the term “states” includes states and territories.

4   Roadmap to Recovery: A Public Health Guide for Governors

 BUILDING THE PUBLIC HEALTH INFRASTRUCTURE
There is consensus among public health experts and federal leaders that preparing for the next phase of
COVID-19 containment will require significant preparation by states to scale up testing, surveillance, and
the public health workforce necessary to identify active cases and limit the risk of outbreaks as economic
functions gradually resume. Such preparation will require federal support, including federal efforts to
expand testing capacity and federal resources to support dramatic expansion of current public health
infrastructures in states. Governors are working with their state health officials to identify gaps and
where expansion is needed. This work should begin as soon as possible to put states in the best position
to assess their unique circumstances and take steps forward with confidence.
The following five steps should be implemented simultaneously.

STEP 1: EXPAND TESTING CAPACITY AND MAKE TESTING
BROADLY AVAILABLE
Widespread testing is necessary to both treat and control infection. It is also essential for early detection
of any increases in COVID-19 cases. However, testing capacity remains inadequate. Barriers to testing
include:
Shortages of critical supplies, including reagents, swabs, lancets, and machines;
Insufficient personal protective equipment (PPE) for healthcare workers performing specimen
collection;
Maldistribution of supplies, owing to an uncoordinated supply chain; and
Mismatch between existing testing efforts and the most urgent needs, such as testing during
outbreaks at nursing homes or of essential workers.

TO EXPAND TESTING CAPACITY, GOVERNORS SHOULD CONSIDER:
Continuing to request that the federal government rapidly build testing capacity and coordinate
distribution to states.
Partnering with the federal government, commercial and academic entities to acquire testing
equipment and supplies such as reagents, swabs and PPE.
Exploring cooperative purchasing and distribution approaches.
Directing state health agencies and other relevant agencies to identify and coordinate various
testing efforts in the state across public, academic and private partners to determine capacity,
match to need and deploy to areas of greatest need.
Expanding access to multiple forms of tests and laboratory capacity to process tests through
public and private laboratories.
Pursuing public-private partnerships to establish drive-through and walk-up testing sites for
wider access across communities.

Roadmap to Recovery: A Public Health Guide for Governors   5

 KEY OPERATIONAL CONSIDERATIONS:
What groups are priorities for testing?
As testing capacity remains limited, prioritization protocols have been established by the federal
government, states and local jurisdictions to ensure availability to those most at-risk first. As capacity
increases, priority groups will shift, and perhaps be eliminated when widely available. Current CDC
recommendations for priority testing are:
Priority 1: Hospitalized patients; symptomatic healthcare workers.
Priority 2: Individuals with symptoms in long-term care facilities, who are 65 years of age
or older, or who have underlying conditions, and first responders with symptoms.
Priority 3: Critical infrastructure workers with symptoms, other individuals with
symptoms, healthcare workers and first responders without symptoms, and individuals
with mild symptoms in communities with high COVID-19 hospitalizations.

How many tests will be necessary?
States need a sufficient number of tests for all priority populations. Testing needs to be widely available
for states to move to later phases of a reopening strategy. Estimates of the number of tests needed
nationally range from 750,000 to tens of millions per week. (See Appendix A for comparisons of
estimates for testing need). Currently the U.S. is able to test approximately 12.1/1,000 people. Germany
has tested 20.9/1000 people, Italy is testing 23.6/1000, and Iceland is testing 125.6/1000.4 Higher levels
of testing in South Korea, Taiwan and Singapore have been a critical element in their ability to control
the spread of the disease. Equally important to increasing the number of tests is ensuring access to key
priority populations.

How can states address supply chain challenges for test kits and supplies and PPE?
On April 16, 2020, the National Governors Association (NGA) released Capacity for COVID-19 Testing
– Current Status and Considerations, a memo to governors explaining the supply issues and outlining
strategies for pursuing additional testing supplies.
States such as California and Connecticut have formed task forces to lead the development, sourcing and
distribution of COVID-19 tests. States can also partner with local academic institutions. For example, the
University of Virginia, Stanford University and New York University have leveraged and shifted internal
resources to be able to manufacture needed reagents for their own tests.
to key priority populations.
Additionally, NGA released Governor Actions to Address PPE and Ventilator Shortages, a memo
highlighting steps governors have taken or may consider to expand access to preserve and repurpose
PPE, procure new resources, build manufacturing capacity and prioritize allocation of PPE.
Among other efforts, states such as Massachusetts are partnering with academic and industry
stakeholders to provide funding and technical assistance to help manufacturers pivot production to PPE
and other in-demand items. States such as New York are turning to 3D printing to produce PPE and
working with other states to address shortages.

Our World In Data. Total Tests for COVID-19 Per 1,000 People. Retrieved from: https://ourworldindata.org/covid-testing. (April 20, 2020). (Note Germany’s data was only
through April 12, 2020).
4

6   Roadmap to Recovery: A Public Health Guide for Governors

 What are promising models for expanding testing capacity?
Promising models could expand access to testing in community settings, reducing the demand on
hospital emergency departments. Examples of these models—including drive-through and walk-up
locations—are featured in the April 16 NGA memo to governors. Key considerations are also outlined in a
guide from the Association of State and Territorial Health Officials (ASTHO).
Emerging technology may also help expand testing capacity. New technologies that should be available in
the future include point-of-care antigen testing and self-administered tests. Their use will become more
clear as evidence becomes available. As with current tests, understanding the quality of testing will be
important to balance rapid scaling and accurate information.

What is the role of antibody testing?
Antibody testing (also referred to as serology testing) offers the promise of identifying individuals who
are immune to COVID-19 for a period of time. Antibody testing is already being used in certain studies to
inform the extent of community exposure and infection. With careful selection of tests and protocols to
balance accuracy with expediency, this could be scaled statewide. In theory, this information could help
to identify people safe to return to the workforce and those lower on the triage list for vaccinations in the
future.
However, many key scientific questions have yet to be answered. These questions include the accuracy
of the many tests on the market, as the U.S. Food and Drug Administration (FDA) has yet to review data
on the vast majority of marketed tests. In addition, it is still unknown the extent to which a measured
antibody response corresponds directly to immunity to disease and the duration of such immunity.
Given these uncertainties, states should continue partnerships with academic institutions on studies that
can pave the way to greater clinical use of these tests and should support the development of guidance
or standards for reliable tests. On April 11, the Trump administration published guidance determining
that the Coronavirus Aid, Relief and Economic Security (CARES) Act requires insurers to cover antibody
testing free of charge, noting that the FDA advises that these tests should not be used as the sole basis
for diagnosis of COVID-19. Additionally, given the novelty of antibody testing, a variety of legal issues
may emerge as states consider potential applications of serology testing for resumption of activities in
populations that may have acquired immunity to the virus.

For more information:
NGA Memo: Capacity for COVID-19 Testing - Current Status and Considerations
NGA Memo: Use of University Laboratories to Produce Necessary Reagents for COVID-19 Testing
ASTHO 16 Key Considerations for Drive-Through and Mobile Testing
Duke-Margolis Achieving Widespread Availability of Timely and Efficient COVID-19 Testing
FDA Emergency Use Authorizations

Roadmap to Recovery: A Public Health Guide for Governors   7

 STEP 2: STRENGTHEN PUBLIC HEALTH SURVEILLANCE TO
UNDERSTAND THE SPREAD OF THE DISEASE AND
RAPIDLY DETECT OUTBREAKS
The federal government as well as multiple expert reports call for evidence of declining transmission
for at least 14 days before states can move to gradual or staged reopening of their economies. Because
reopening society—even through incremental steps—will bring the risk of increased transmission, states
must continue to closely monitor signs of COVID-19 spread. States that fail to do so, or without adequate
test and trace capability in place, will only notice problems when individuals begin to crowd emergency
departments and outbreaks among the most at risk are reported. By that point, it may be too late to
avoid larger scale community spread which would bring another wave of critically ill patients that could
overwhelm the healthcare system and require a return to much more extensive “stay in place” measures.
Test results for COVID-19 are an important way to monitor spread. However, testing is limited in many
areas and may be particularly difficult to access for some high-risk populations. As a result, states
should work closely with existing state and federal surveillance systems and expand state capacity
to assess for potential COVID-19 spread, utilizing a broad range of data sources. These data must be
consolidated, analyzed and reported rapidly to provide real-time intelligence on the pandemic.

TO STRENGTHEN SURVEILLANCE SYSTEMS, GOVERNORS
SHOULD CONSIDER:
Charging state health agencies with building on foundational surveillance systems to
coordinate multiple channels of data for decision making on COVID-19.
Requiring COVID-19 data reporting that is needed but not already mandated for this system
from laboratories, hospitals, ambulatory care settings and other locations.
Supporting the technology needs for collection, analysis and reporting of time-sensitive testing
and other clinical data to state health agencies with adherence to existing privacy and security
frameworks.
Developing other surveillance methodology such as obtaining information on employee
absenteeism due to illness from the private sector.

KEY OPERATIONAL CONSIDERATIONS:
How can states build a strong surveillance capacity?
COVID-19 surveillance capacity can be built on the foundation of existing systems at the Centers for
Disease Control and Prevention (CDC) and in state health agencies. States generally require laboratory
and provider reporting of infectious diseases, outbreak reporting, and sentinel surveillance for influenzalike illness and other diseases of interest.
The CARES Act requires the reporting of both positive and negative tests for COVID-19, in order to
monitor the change in percentage of positive tests over time, which is a quantitative indicator of disease
activity. States can add to reporting requirements to collect more standardized data on age, gender, race,
and location in order to monitor the spread of disease in different populations.
8   Roadmap to Recovery: A Public Health Guide for Governors

 Beyond testing, states can expand sentinel surveillance of target populations and syndromic surveillance
to include indicators of COVID-19 activity, such as emergency department visits and hospital admissions
for confirmed and COVID-19-like illnesses. Surveillance should also include other high-risk settings,
such as nursing homes, assisted living, senior housing, jails, and prisons.

How can states facilitate the sharing of COVID-19 data with state health agencies for surveillance?
States can facilitate the sharing of COVID-19 data by requiring new reporting, reiterating existing
requirements or refining guidance where necessary to:
Increase the number of entities reporting (e.g., laboratories, hospitals, ambulatory care setting);
Increase and standardize electronic reporting;
Standardize data collection;
Improve timeliness of data reporting;
Leverage existing data networks and available data;
Leverage private/public partnerships; and
Ensure privacy and security of all data.
States should also explore whether they have a health information exchange that can repurpose existing
tools to quickly collect and share data. For example, health systems may be able to report information
to a health information exchange, which can then aggregate the information to pass to the state health
agency.

How can states expand syndromic surveillance for conditions related to COVID-19?
Syndromic surveillance allows for early identification of illness clusters, before diagnoses are confirmed
and reported to public health agencies and the mobilization of a rapid response, thereby reducing
morbidity and mortality. The National Syndromic Surveillance Program includes data from over 70% of
U.S. hospitals and other reporting entities and maintains data security and privacy protections.5 State
health agencies can use information from this platform in constructing their own surveillance system for
COVID-19.

Is antibody testing appropriate for COVID-19 surveillance?
As reliable antibody tests and testing protocols are identified, states can conduct population-based
surveillance studies to better understand the population exposure to the virus. (See additional
information on antibody testing in the testing section).
For more information:
Duke-Margolis A National COVID-19 Surveillance System: Achieving Containment
Council of State and Territorial Epidemiologists Driving Public Health in the Fast Lane
CDC National Syndromic Surveillance Program (NSSP)

5

Centers for Disease Control and Prevention. National Syndromic Surveillance Program. Retrieved from: https://www.cdc.gov/nssp/overview.html (April 20, 2020).

Roadmap to Recovery: A Public Health Guide for Governors   9

 STEP 3: DRAMATICALLY SCALE CAPACITY FOR ISOLATION, CONTACT
TRACING, AND QUARANTINE
Strict social distancing has been effective at decreasing the rate of infection, yet has resulted in
significant economic and social consequences. As states plan for potential loosening of social distancing
orders and a gradual, phased reopening of economic sectors or geographic areas within them, a targeted
approach to (i) isolate and monitor actively infected persons, (ii) identify and test (if needed) contacts of
infected persons, and (iii) quarantine and monitor those contacts for 14 days will be needed.
State and local health agencies already have significant experience in employing case-based strategies
to reduce the spread of infectious disease like tuberculosis, sexually-transmitted infections, and
measles. Scaling these efforts to the unprecedented levels needed to respond to COVID-19 will require an
expanded, well-trained workforce that builds on existing state disease investigation capacity; adequate
systems to monitor and support infected individuals and contacts; consultation and technical assistance
from CDC; and social resources for cases and contacts to ensure compliance with public health guidance.

TO SUPPORT DRAMATIC SCALING OF ISOLATION, CONTACT TRACING,
AND QUARANTINE, GOVERNORS SHOULD CONSIDER:
Directing state health agencies to determine what contact tracing and disease investigation
capacity already exists at the state and local level to determine what will be needed for
expansion.
Removing barriers and mobilizing resources, under public health emergency authorities if
necessary, for directly hiring staff or collaborating with private sector entities (such as health
systems) to hire staff and coordinate outreach activities.
Working with public and private sector leaders to identify sources of contact tracing staff (e.g.,
municipal workers such as librarians or other technical professionals; healthcare professionals;
census workers; students; and others).
Developing policies for monitoring isolated COVID-19 cases or quarantined contacts and
providing wrap-around services to support individuals in isolation and quarantine. These
resources may include alternative housing if needed, food and medication delivery, and other
services.
Ensuring the right technologies and data tools are in place to provide case management
services, monitor isolation and quarantine activities and measure outcomes of large-scale
contact tracing.

KEY OPERATIONAL CONSIDERATIONS:
How many individuals and what level of skill are needed for contact tracing?
A significant increase in the existing contact tracing public health workforce is needed to address the
anticipated numbers of infected persons in the U.S. and effectively control and decrease infection rates.
In a recent report, Johns Hopkins and ASTHO estimated a need between 4 and 81 tracers per 100,000
population, based on level of illness. This estimate is based on robust contact tracing efforts underway
in Massachusetts, Seattle, and internationally in South Korea, Iceland, and Taiwan. The level of skill
and composition of contact tracing teams will depend on a state’s geography, existing local and state
1 0   Roadmap to Recovery: A Public Health Guide for Governors

 assets and expertise, the available workforce and recruiting efforts, and disease burden. Generally,
states can consider deploying teams of varying combinations of three groups: (1) entry-level, “lay” and
paraprofessional contact investigators, (2) professional disease investigation specialists (DIS), and (3)
advanced response professionals, including epidemiologists, clinical and medical specialists and potential
federal service officers or members.

What is the estimated cost to implement this testing, isolation, contact tracing and quarantine effort?
ASTHO requested $3.6 billion in emergency funding from Congress for an estimated 100,000 person
workforce nationally, using a $17 per hour base pay rate. Beyond the additional workforce, funding will
be needed for wrap-around support services for individuals who may require assistance to comply with
isolation and quarantine, such as health, housing and nutrition services. Funding will also be needed for
any technology or data tools, as well as interface costs, to support contract tracing.

Where can states look for people to serve in an expanded public health workforce?
One option for states is to partner with organizations experienced in contact tracing. Massachusetts has
partnered with local agencies and the non-profit organization Partners In Health to rapidly scale up
training and hiring of 1,000 contact tracers. When fully staffed, Massachusetts will hire about 14 contact
tracers per 100,000 residents.
An alternative is to partner with colleges and universities. Florida hired 100 workers for contact tracing
over a single weekend by reaching out to its varied Schools of Public Health and hiring faculty and
graduate students.
States may also consider hiring competent, trained individuals from within heavily affected communities,
which may include furloughed or laid off workers, to serve as community health workers. These
individuals can enhance trust in the public health response, conduct contact tracing, and link people
to critical resources. Because of the nationwide public health emergency and national emergency
declarations, state workforce agencies can apply to request funding for Disaster Recovery Dislocated
Worker Grants (DWGs) and Economic Recovery DWGs. Several states have submitted emergency
funding requests for training activities related to COVID-19 response and recovery needs, in addition to
leveraging certain other existing Workforce Innovation and Opportunity Act (WIOA) funding streams.
States can take additional steps to support hiring for COVID-19 response occupations, such as facilitating
virtual hiring events and matching workers to fill health care and other emergency response and
supply chain workforce needs. For example, Indiana hosted a virtual job fair focused specifically on job
openings in the healthcare industry within five hospital systems in Northeast Indiana. Governor Newsom
partnered with the technology platform, OnwardUS, to launch a portal that links displaced workers with
employers across the state, including those with jobs related to COVID-19 response needs.

What is the role of technology in supporting isolation, contact tracing and quarantine?
While manual contact tracing, with its personal outreach and direct case and contact engagement, is
considered the bedrock of highly effective contact tracing, technology can play a critical role in managing
workflow activities in case/contact engagement, monitoring symptoms and effectiveness in isolation or
quarantine actions, as well as increasing the efficiency and effectiveness of these widespread efforts at
the community level. These technologies should be effective at advanced analytics and visualization to
monitor and optimize contact tracing activities.
States may consider how smartphone apps and web-based tools can securely and confidentially help to
notify individuals who come into contact with COVID-19 positive individuals and help them monitor their
own symptoms to identify the potential need for testing. For example, Governor Burgum recently

Roadmap to Recovery: A Public Health Guide for Governors   11

 announced a new mobile app, Care19, that allows users testing positive for COVID-19 to consent to
sharing accurate real-time data with the North Dakota Department of Health to support contact tracing
and forecasting the pandemic’s progression.
States will need to consider both privacy concerns and people’s willingness to participate with this
type of technology. Issues such as mobile phone app ownership, implementation, and data storage will
also be important considerations for states in the weeks and months to come. Ensuring there is clear
communication to and understanding of the public on how information is kept, used, and deleted is
critical. Data used for contact tracing should be maintained for tracing purposes only, not shared for
research or other purposes, and should be purged after appropriate use.

How can states offer support for those in isolation and quarantine and provide alternative
isolation locations?
Contact tracers who identify positive cases and their contacts must facilitate rapid isolation and
quarantine of these individuals. States have a vital role to play in making critical services that enable
isolation and quarantine possible. These may include providing:
Relocation to alternative locations—such as repurposed hotels, dormitories, or military barracks—
for individuals in need of stable housing or unable to isolate or quarantine effectively at home;
Access to medical care, food, childcare and other needs; and
Basic financial support for the period of isolation and quarantine.

How can states best encourage compliance with isolation and quarantine policies
States should work with local officials to develop policies to encourage compliance with isolation
and quarantine and explain these policies to the public early and transparently. Public trust and
understanding is critical for successful implementation. States should continue to evaluate the
effectiveness of these policies and how they may need to be modified.
For more information:
ASTHO/JHU A National Plan to Enable Comprehensive COVID-19 Case Finding and Contact Tracing in
the US
ASTHO A Coordinated, National Approach to Scaling Public Health Capacity for Contact Tracing and
Disease Investigation
JHU Review of Mobile Application Technology to Enhance Contact Tracing Capacity for COVID-19
World Health Organization Implementation and Management of Contact Tracing for Ebola Virus
Disease
Vital Strategies Resolve to Save Lives Contact Tracing Protocol

1 2   Roadmap to Recovery: A Public Health Guide for Governors

 STEP 4: ENSURE THE STATE’S HEALTHCARE SYSTEM CAN RESPOND
TO POTENTIAL SURGES
As healthcare systems grapple with the first wave of COVID-19 infections, governors have played
central roles increasing the surge capacity of the healthcare systems in their states. Steps have included
obtaining PPE, securing ventilators, redistributing the healthcare workforce, and establishing additional
workforce and hospital capacity. To prepare for the gradual reopening of the economy, states must
ensure that their healthcare systems are out of crisis mode and able to handle potential new surges in
patients, along with non-COVID-19 related services.

TO ENSURE SURGE CAPACITY, GOVERNORS SHOULD CONSIDER:
Developing metrics to assess the healthcare system’s ability to safely treat both COVID-19
patients and all other patients requiring care without resorting to crisis standards of care.
Requiring healthcare providers to continuously report on numbers of healthcare worker
infections, number of hospital beds, and levels of PPE and other medical equipment (such as
ventilators) across the healthcare system.
Partnering with industry and academic institutions to support PPE manufacturing.
Removing regulatory barriers to establishing alternative sites of care or repurposing existing
sites to serve COVID-19 patients in a surge.
Expanding the pool of in-state and out-of-state licensed health care providers, expanding the
use of telehealth, and ensuring appropriate liability protections.
Expanding support for healthcare workers, including services such as childcare and eldercare.

KEY OPERATIONAL CONSIDERATIONS:
What levels of hospital surge should states prepare for?
As noted in the report from the American Enterprise Institute (AEI), recommended minimal surge
capacity in hospitals to respond to increasing incidence of COVID-19 disease includes the ability to
expand critical care beds in hospitals from 2.8 to 5-7 beds per 10,000 adults with accompanying staffing,
PPE, equipment, oxygen and medication. Likewise, hospitals must be able to expand access to ventilators
from 3 to at least 5-7 ventilators per 10,000 adults, accompanied by adequate staffing and supplies.
During this time, hospitals must also maintain access to acute care hospital beds of at least 30 per
10,000 adults with planning for flexible use of these beds. Mobile health care infrastructures such as tent
structures and temporary use of alternate sites, with state and federal support, are other solutions for
surge capacity needs.
Examples of field hospitals and tent structures can be seen in New York, Washington, and Florida.
Repurposing of entertainment venues have been done in states like Maryland, with the creation of
a Federal Medical Station, through federal-state and public-private partnerships with local hospital
systems.

Roadmap to Recovery: A Public Health Guide for Governors   13

 How can states assess hospital capacity?
States can partner with healthcare systems, hospital associations and emergency management agencies
to determine hospital capacity, including bed availability, staffing limits, equipment, medication supplies
and PPE. States can use electronic monitoring databases and calculators, such as HavBed for hospital
bed availability and the CDC PPE Burn Rate Calculator. States may also consider implementing processes
to ensure that hospitals and healthcare systems have bed capacity, PPE for workers and are collecting
complete data including self-reported racial and ethnic status.
States should also consult with their boards of pharmacy and other pharmaceutical supply chains to
assess the potential of critical shortages of medications and to develop plans to prevent them.

How can states assess the ability of their healthcare systems to care for patients with cancer, mental
illness, addiction and other conditions besides COVID-19?
States can partner with their local medical societies and other groups of community-based providers
to track access to core health services over time. For example, governors can engage behavioral health
organizations to identify challenges in maintaining support for people with mental illness and/or
substance use disorders and prepare for an increase in volume resulting from the pandemic. Using
existing state, local and provider networks, providers can report on the number of visits in different
categories in primary care and by specialty, including mental health and addiction services. This
reporting can also include identifying financial vulnerabilities of specific providers, access to necessary
PPE and other supplies, access to testing for healthcare workers, and changes made to support
social distancing. States can use this information to identify gaps in key services for specific patient
populations and develop initiatives to address them.

How can states build an adequate healthcare workforce for a surge?
States can identify different ways to recruit healthcare providers. Strategies include expanding access
to out-of-state licensed health care providers and telehealth, maintaining and increasing the number
of providers by easing in-state licensure requirements and expanding the pool of clinical and nonclinical health care workers by expanding scope of practice, reducing supervisory requirements,
providing reimbursement to providers serving in new capacities, letting providers practice at the top
of their license, and credentialing veterans and foreign trained providers. States also may partner with
the federal government, through the Federal Emergency Management Administration (FEMA) or the
Veteran’s Administration for potential deployment of medical personnel. NGA has released a memo on
Gubernatorial Strategies for Healthcare Workforce and Facility Capacity with additional recommendations
on building workforce capacity.
For more information:
NGA Memo: Governor Actions to Address PPE and Ventilator Shortages
NGA Memo on COVID-19 and Medical Surge
NGA Memo on Strategies for Telehealth
NGA Memo on Strategies for Health Care Workforce and Facility Capacity
Electronic database for hospital beds, HavBed
CDC PPE Burn Rate Calculator

1 4   Roadmap to Recovery: A Public Health Guide for Governors

 STEP 5: PROTECT ESSENTIAL WORKERS AND AT-RISK POPULATIONS
Opening public spaces will entail an increased risk of community transmission. Certain populations will
be more at risk for serious consequences and mortality from contracting the disease. Those most at risk
include:
Healthcare workers, first responders and other essential workers in contact with the public;
Older adults living in nursing homes, assisted living, and senior housing;
Racial and ethnic minorities;
Justice-involved populations;
People experiencing homelessness; and,
People with disabilities and living in state institutions, group homes, and other congregate settings.
Given the setting and circumstances of where these populations reside, targeted monitoring and
interventions will be critical to protecting these communities. States that develop effective systems and
policies that protect these populations will be less likely to experience outbreaks that can interrupt the
gradual reopening of society.

TO PROTECT THOSE AT HIGHER RISK, GOVERNORS SHOULD
CONSIDER:
Designating a lead agency to develop and implement a strategy for older adults that includes
establishing preventive standards, expanding the availability of home health care, providing
wraparound nutrition and mental health services, and standing up a strike team to respond to
outbreaks of disease.
Developing standards for the protection of essential workers in contact with the public,
including access to PPE, cleaning supplies, and sick leave benefits.
Appointing an advisory committee on emerging racial disparities in COVID-19 deaths with
representation from affected communities.
Implementing early release or utilizing alternatives to incarceration consistent with public
safety to reduce crowding in correctional facilities, and identify supports in the community,
while taking steps to reduce in-person contact points for those inside facilities.
Appointing an advisory committee to address unique needs of the disabled, homeless, and
other communities with access and functional challenges with representation from affected
communities.

Roadmap to Recovery: A Public Health Guide for Governors   15

 KEY OPERATIONAL CONSIDERATIONS:
How can states put together rapid response teams for at-risk populations?
Key components of response teams include infection control experts from public health, access to critical
testing and supplies, and support for evacuation from the National Guard or other similar resources. As
an example, Governor Hogan in Maryland and Governor Gina Raimondo in Rhode Island have established
strike teams to respond to critical incidents in nursing homes.

What standards can states set to protect essential workers?
There is a broad range of essential workers who are at increased risk of transmission from healthcare
providers and first responders to grocery workers and bus drivers. In partnership with employers and
local governments, states can set standards for different categories of workers to ensure their safety
such as redesigning the work environment, providing hazard pay, providing supplies for cleaning, access
to recommended masks, and sick leave benefits. For example, Governor Mills issued an executive order
restricting the number of people allowed at essential businesses at any one time and requires businesses
to implement a broad range of workplace hygiene measures and implement physical distance policies, to
the extent possible.

How can states assess the need for PPE for high risk settings?
States can assess the need for PPE in different settings, such as nursing facilities, jails and prisons.
Obtaining these supplies should be prioritized in order to reduce the potential for major outbreaks. CDC
has a published PPE Burn Rate Calculator for facilities to assess ongoing PPE needs. New Hampshire has
a PPE Request Form for COVID-19 for its healthcare providers to report PPE needs.

How can states partner with local governments and community-based organizations to build effective
policies and provide wrap around services for older adults and individuals with disabilities?
States may provide clear guidance for facilities and providers that serve older adults and individuals with
disabilities around safety measures, needed equipment (PPE), handling hospital discharge and overflow,
ensuring effective workforce and best practices around early identification and response to outbreaks.
Centers for Medicare and Medicaid Services (CMS) recently issued new regulatory requirements that
nursing homes inform residents, their families and representatives of COVID-19 cases in their facilities.
States may partner with local government and community-based organizations to support providers
and caregivers serving these populations as well as meeting increased demands for meals and other
wrap around services for those living in the community. Several states have secured additional funding
through the Medicaid program to support some of these efforts. For example, 18 states have received
approval from CMS to pay family caregivers for care of older adults during this public health emergency.
A number of states have also received approval for services such as home-delivered meals (7 states) and
additional medical equipment and supplies like PPE (8 states).

How can states address emerging evidence of racial and ethnic disparities in COVID-19 deaths?
Early evidence demonstrates significant disparities in rates of COVID-19 death by race. For example,
African Americans are dying at a rate of two to three times the rate for the general population in
Louisiana, Illinois, and Michigan, and at substantially higher rates in the District of Columbia, Maryland,
North Carolina and Connecticut. Higher rates of death among Latino populations have been reported in
New York City and elsewhere.

1 6   Roadmap to Recovery: A Public Health Guide for Governors

 The reasons for these stark disparities, particularly for lower income populations, include limited
access to health care, overrepresentation in jobs with inadequate PPE, unstable or crowded housing
arrangements that make it difficult to isolate and quarantine, overexposure to environmental pollutants
that may predispose to severe disease, and high rates of chronic illness.
Addressing these disparities starts with a commitment to measure them in a culturally-informed manner
that engages communities. According to JHU, many states do not report race and ethnicity in testing,
confirmed cases and deaths. States may expand this reporting, including by relying on the healthcare
systems in their state that are able to track and provide these data more effectively. Other steps include
developing pathways for COVID-19 testing and services to undocumented populations or people without
access to healthcare services; setting standards for protection of essential workers; offering support such
as food delivery (or even hotel stays) for people who must isolate or quarantine, and partnering with
community leaders to ensure strong communication, engagement, and planning. To help address these
needs, Michigan Governor Gretchen Whitmer established a task force that includes community members
from the most impacted areas to investigate and propose strategies to address disparities in her state.

How can states best reduce the chance of outbreaks among individuals experiencing homelessness?
The CDC has guidance on how to reduce the risk of COVID-19 among individuals experiencing
homelessness. The U.S. Department of Housing and Urban Development also maintains a website with
guidance and resources. In general, providing housing to individuals who are experiencing homelessness
will most rapidly reduce the risk to this population.
States may take steps such as (i) waiving certain regulatory barriers for any shelters or facilities, (ii)
directing state, local and private sector partners to transition sheltered homeless individuals into
alternative housing that allows for adequate social distancing, (iii) directing social service agencies to
continue providing basic food, water, shelter and hygiene needs, (iv) assist localities in partnering with
the commercial sector (such as hotels, motels or trailers) to secure temporary housing with a plan for
separate locations for people who test positive; and (v) engage underutilized community-based providers
(e.g., community mental health centers) to engage the population in mitigation approaches.

How to address increased risk for incarcerated populations?
Governors can work with correctional leaders to reduce risks for justice-involved juveniles and adults.
Strategies for reducing crowding in correctional facilities have included implementing early release for
individuals who are medically compromised or with low-level, non-violent offenses, as well as utilizing
alternatives to incarceration for pre-trial individuals. CDC guidance outlines strategies for reducing the
risk of COVID-19 and responding to outbreaks in jails and prisons. The NGA has issued memos on early
release from detention and juvenile justice. JHU has released additional recommendations.

Roadmap to Recovery: A Public Health Guide for Governors   17

 For more information:
NGA Memo: Strategies for COVID-19 Response for Older Adults and People with Disabilities
NGA Memo: Gubernatorial Strategies for Health Care Workforce and Facility Capacity
NGA Memo: COVID-19 Responses in the Juvenile Justice System
NGA Memo: Early Release from Incarceration in Response to COVID-19
NGA Memo: Child Care Needs During COVID-19 Closures
CDC Interim Guidance on People Experiencing Unsheltered Homelessness
CDC Interim Guidance on Management of Coronavirus Disease 2019 (COVID-19) in Correctional and
Detention Facilities
Department of Housing and Urban Development COVID 19 Prevention and Response for Homeless
Providers: Daily Resource Digest
JHU Recommendations for a Metropolitan COVID-19 Response – Special Emphasis Series – Guidance
on Protecting Incarcerated Individuals

1 8   Roadmap to Recovery: A Public Health Guide for Governors

 CREATING AND EXECUTING A PLAN TO GRADUALLY
REOPEN THE ECONOMY
With a strong public health infrastructure in place, states will begin to gradually reopen the economy.
Critical decisions on reopening will require a step-by-step process to weigh the risks and benefits.
Governors will lead in determining when, where, and how to gradually resume economic activities, when
social distancing or other mitigation measures may need to be adjusted or reinstated, and how to clearly
and effectively communicate with businesses and the public to reduce the risk of outbreaks.
The following are important steps for governors to protect the public’s health on this path to recovery.
There are a number of other economic considerations for reopening businesses that are not addressed
in this report; however, the steps to develop the plan here may be leveraged in planning for longer term
economic recovery.

STEP 6: DEVELOP A STRONG AND CLEAR COMMUNICATION AND
PUBLIC ENGAGEMENT PLAN
In a crisis, communication is not simply informing people about actions being taken by state officials.
Communication is an integral part of the response itself. Effective communication encourages
individuals, families, businesses and neighborhood groups to take actions that protect themselves and
their communities.
Communication becomes even more important as states move toward reopening. There is a risk of
misunderstanding, confusion, or protest by people who believe that the pace of change should be either
faster or slower.
A critical element of communication is public engagement. Different communities will have different
needs, risk factors, and resources. Through intensive discussions across their states, governors can forge
a path forward with broad public support.

TO COMMUNICATE AND ENGAGE EFFECTIVELY, GOVERNORS
SHOULD CONSIDER:
Regularly holding press conferences to explain the status of the pandemic and key steps being
taken to protect the public.
Creating the opportunity for extensive public engagement about plans for reopening the
economy.
Collaborating with other trusted individuals, including physicians, nurses, business leaders,
public health experts, community leaders, non-profit organizations, faith leaders as well as
persons from communities who have recovered from COVID-19 infection.

KEY OPERATIONAL CONSIDERATIONS:
What are core elements of effective communications in a crisis?
According to the CDC’s guide to communication in a public health crisis, critical elements of effective
communications include timeliness, accuracy, and credibility. Transparency, candor, and the public
release of data all foster credibility. So too does the support of healthcare and public health leaders with
sterling reputations in their fields and in the community.
Roadmap to Recovery: A Public Health Guide for Governors   19

 Many governors have found success with regular briefings with public health officials that review a
consistent set of critical metrics, describe key challenges candidly, explain what is being done to address
the challenges, and provide room for hope. Governors can connect with their communities by conveying
empathy about loss, acknowledging and responding to the disproportionate impact of the COVID-19
crisis on certain communities, and by appreciating a broad range of efforts to address critical needs.
Governors also can acknowledge where uncertainty exists and indicate that new information may bring
about changes to recommendations.

What is the role of the private sector in communication?
Governors can build important and influential communication partnerships with the private sector.
Media outlets can cover news conferences and provide public service announcements. Faith and
community leaders can amplify key messages, including translating critical health information
into different languages. Nonprofit organizations can reach a broad diversity of neighborhoods and
communities. Governors have also partnered with communications firms to develop media campaigns
leveraging paid and donated airtime, billboards, print ads and social media posts to encourage
communities to adhere to stay at home orders and practice other safe behaviors. The Ohio Department
of Health’s 30-second “mousetrap” ad, which visually illustrates the effectiveness of social distancing,
was seen by 9 million viewers within its first 24 hours. In Minnesota, Governor Tim Walz launched
#StayHomeMN, a marketing campaign to provide information to Minnesotans on how to keep their
communities safe.

What is the best way to communicate on difficult topics (such as isolation and quarantine), needed
safety measures upon reopening, and when social distancing measures must be reinstated?
Difficult topics should be addressed by a state’s most trusted messengers, often the governor and state
health officials themselves. It can help to bring together support from trusted validators across the
public and private sectors. As the CDC guide to communications recommends, it also helps to map key
messages in advance, along with answers to anticipated questions.

What are best practices for public engagement?
Governors can convene formal advisory committees or develop structured opportunities for different
sectors to partner with state leaders. These forums should be structured to provide meaningful
opportunity for two-way dialogue. Special efforts should be made to engage with at-risk communities,
young people, racial and ethnic minorities, individuals with disabilities, and others who may have less
access through formal channels. Written public comment on draft documents can provide an opportunity
for everyone to have input into key decisions. Governors may also consider specific communication
strategies and engagement geared toward front-line healthcare workers, who are experiencing high
levels of stress and uncertainty.

How can states discuss the potential for effective treatments and vaccines?
While there are many potential treatments and vaccines for COVID-19, none have yet been demonstrated
to be safe and effective. Patients can access experimental therapies through clinical studies,
compassionate use with the consent of manufacturers, or for treatments that are already on the market
for another purpose, through their physicians as part of clinical practice.
For treatments that are still under investigation, governors and state health officials can explain that it
is not known whether the potential benefits exceed the potential harms. Even currently marketed drugs
for other purposes can have serious harms for patients with COVID-19. That’s why the decision to begin
treatment should be left to the individual patient and doctor.

20   Roadmap to Recovery: A Public Health Guide for Governors

 Governors can discuss experimental treatments to emphasize the value of research to communicate
which treatments work and which do not. In partnership with academic institutions, states can
encourage people to participate in research studies to generate evidence about what works, for which
patients, at which stage of illness, and at what dose.
Governors can also communicate that when evidence establishes safe and effective treatments or vaccine,
the state will need to develop strategies to provide appropriate access and affordability for those who
need them. Looking forward, governors will need to prepare for the later phases of response such as
ensuring mass distribution of vaccinations and/or treatments when they are approved and available for
the public.
For more information:
CDC Crisis & Emergency Risk Communication
ASTHO COVID-19: Simple Answers to Top Questions - Risk Communication Field Guide Questions
and Key Messages

STEP 7: CREATE A FRAMEWORK FOR REOPENING
Governors are well underway in developing frameworks that thoughtfully guide decision making on key
factors to reopen the economy. These frameworks include important public health factors such
factors as:
Communicating a consistent description of the ongoing challenge of COVID-19;
Providing evidence on the effectiveness of social distancing to date;
Collecting data on COVID-19 spread;
Emphasizing the importance of testing, isolation, contact tracing, and quarantine;
Defining specific measures to assess readiness for reopening;
Establishing criteria to be used for moving between phases of response;
Determining how the state will assess for a resurgence of COVID-19; and,
Anticipating the potential necessity of returning to tighter community control measures.
Several Governors have announced preliminary guidelines or skeletal plans for reopening, or have
appointed task forces composed of state officials and private sector leaders to help guide reopening
decisions. For example, Governor Polis has outlined a process for recovery in three stages (urgent,
stabilization, and recovery) and released key indicators required for consideration of relaxing social
distancing. Governor Parson’s “Show Me Strong Recovery” plan includes four essential pillars:
expanding testing capacity, expanding PPE reserves, expanding health system capacity, and improving
the ability to predict potential outbreaks.
Governors also are forming regional coalitions to coordinate their efforts. Using similar approaches to
reopen across regions can provide a cohesive approach and minimize public confusion or frustration. To
date, a Western (California, Oregon, Washington), Midwestern (Michigan, Ohio, Wisconsin, Minnesota,
Illinois, Indiana, Kentucky) and Eastern (New York, New Jersey, Connecticut, Pennsylvania, Delaware,
Rhode Island) coalition of states have been formed to address reopening procedures.
Roadmap to Recovery: A Public Health Guide for Governors   21

 TO DEVELOP A FRAMEWORK FOR REOPENING, GOVERNORS
SHOULD CONSIDER:
Creating a process for ongoing public input and engagement, including the potential
designation of a broad-based task force or advisory committee.
Regionalizing approaches to recovery by collaborating with neighboring states.
Communicating clearly about the framework and what it means for individuals, businesses,
and communities.
Developing a public facing dashboard of key metrics to inform the implementation of the
framework.
Leveraging the established framework as a foundation for a longer-term economic recovery
plan and beginning to identify future goals.

KEY OPERATIONAL CONSIDERATIONS:
Who should be included in efforts to develop and implement the framework for reopening?
Stakeholders include public health officials and other state officials, employers, workforce development
leaders, healthcare systems and providers, local governments (including counties and cities), consumers,
educators, chambers of commerce, community leaders and others. Representatives from at-risk
communities and those who have been disproportionately affected by the disease, such as lower-income
African Americans, Latino and Native Americans, are important stakeholders.

What data elements will inform the development and implementation of a framework?
As described in more detail under Step 8, states may consider developing goals and indictors to inform
decisions on loosening and tightening social distancing as part of plans for reopening. The categories
may cover public health metrics to map the spread of disease, as well as a broad range of preparedness
capabilities, including surveillance for signs of illness, testing capacity, hospital surge capacity, progress
in isolation, contact tracing and quarantine, and efforts to reduce infections in public with masks, hand
sanitizer and other recommendations for employers.

How can states address issues of interstate travel?
Governors and state health officials will need to develop a plan for addressing interstate travel and
tourism, including travel to and from one state to another state that may have high incidence of
COVID-19.
As mentioned previously, states could establish regional partnerships to address questions of interstate
travel and support consistency across metro areas. Several partnerships have formed among West Coast,
Midwest and Northeastern states.

22   Roadmap to Recovery: A Public Health Guide for Governors

 For more information:
JHU Public Health Principles for a Phased Reopening During COVID-19: Guidance for Governors
AEI National Coronavirus Response: A Road Map to Reopening
Harvard Safra Center Roadmap to Pandemic Resilience

STEP 8: SET THE CRITERIA AND DEFINE THE STAGES
FOR REOPENING
Two essential elements of state frameworks for reopening the economy are the criteria for moving
between levels of social distancing and determining the process by which states and local governments
will gradually expand allowable activities. With public input and engagement, and informed by public
health evidence and expertise, states, in partnership with local governments, should begin to set these
elements in place.

TO SET THE CRITERIA AND STAGES OF REOPENING, GOVERNORS
SHOULD CONSIDER:
Identifying key public health and preparedness capability metrics for initiating the process of
reopening.
Setting a length of time to ensure that there is no surge in cases before proceeding to the next
level of social distancing.
Developing clear public health criteria for when social distancing criteria may be loosened or
tightened.
Prioritizing public and private activities for different stages of reopening.

KEY OPERATIONAL CONSIDERATIONS:
What are key criteria for starting the process of reopening?
Multiple experts have advised that states begin to reopen when the number of COVID-19 infections is
in sustained decline, when the healthcare system is able to care for patients and not operate in crisis
mode, and when protocols are implemented to protect high risk populations are in place. Experts also
recommend that states build the public health infrastructure for effective surveillance, isolation, contact
tracing, and quarantine. Appendix A summarizes federal and key expert recommendations for reopening
and Appendix B outlines a list of potential goals and criteria that states may consider when identifying
how to determine readiness for gradual reopening.

Roadmap to Recovery: A Public Health Guide for Governors   23

 How can states determine the relative risks of different public and private sector activities in order to
define the stages of reopening?
To assess the risk of different activities, state officials may consult expert reports and guidance (such as
those summarized in this JHU report) and obtain input directly from affected agencies, businesses and
local governments. Key criteria include contact intensity, the number of contacts, and the modification
potential of each activity. Potential modifications for discussion include telework, increased number of
shifts, curbside customer interaction, hands free technology, the ability to distance customers and the
ability to distance staff.
States will need to prioritize certain activities (return to work and school, for example) over other
activities (such as large indoor concerts) based on their economic and public health impacts.

How can states identify or define regions with different risk profiles within a state?
Statewide versus regional opening strategies will need to be considered by gauging economic and health
impacts that are specific to each state. Governors can work with local officials to support a targeted
approach to reopening that recognizes that different counties and jurisdictions have varying risk profiles.
Utilization of forecast modeling can help guide disease activity predictions.
For more information:
NGA Memo: Implementing Effective Social Distancing Policies to Mitigate Spread of COVID-19
NGA Memo: Overview of State Actions on Business Closure and Personal Movement Restrictions in
Response to COVID-19
CDC Community Mitigation Guidelines to Prevent Pandemic Influenza - United States, 2017
JHU Public Health Principles for a Phased Reopening During COVID-19: Guidance for Governors

STEP 9: BUILD PARTNERSHIPS BETWEEN PUBLIC AND PRIVATE
SECTORS TO IMPLEMENT THE PLAN
To effectively implement their frameworks for reopening, states will need to partner with businesses
and local governments in identifying what activities will be permitted at each stage, as well as mitigation
measures to reduce the risk of activities in public settings. Clearly communicating next steps, rationale,
and guidance as states relax community-wide social distancing policies will encourage individuals,
families, agencies and businesses to take necessary action to reduce risks and support a sustained and
successful reopening process.
States will also need to combine this public engagement with appropriate tools and mandates to ensure
effective implementation. For example, Pennsylvania has required essential employees to wear cloth
masks. Idaho is requiring certain businesses to develop preparedness plans.

24   Roadmap to Recovery: A Public Health Guide for Governors

 TO SET THE CRITERIA AND STAGES OF REOPENING, GOVERNORS
SHOULD CONSIDER:
Developing and promoting tools to help public and private organizations reduce their risks of
COVID-19 transmission and respond to early signs of outbreaks.
Setting standards for reporting on the progress of reopening, such as COVID-19 infections and
employee absenteeism.
Reopening key public functions, such as the court system and motor vehicle administration.
Assigning liaisons to key business groups such as Business Roundtables, Chambers of
Commerce, or other key organizations and establishing clear feedback loops to support
reopening and ongoing assessment of the reopening process.

KEY OPERATIONAL CONSIDERATIONS:
How can states help businesses reopen safely?
States can create a template or checklist to help agencies and businesses reopening, with space for
steps in four key areas as noted by a recent JHU report: physical distancing, engineering controls,
administrative controls, and PPE. The White House Coronavirus Taskforce’s reopening guidelines also
advises businesses to develop appropriate policies to protect workplace safety in accordance with federal,
state, and local regulations and guidance, as well as industry best practices.
For example, public agencies and private businesses should identify modifications that are compliant
with existing federal and state laws for:
Physical distancing, such through telework and shift work, employee
illness screening, and sick leave and family leave policies;
Engineering controls, such as hands free technology, the creation of
barriers between people, and more frequent cleaning;
Administrative controls, such as decreased customer/client interactions; and
PPE, such as masks and other equipment.
The checklist could include sections for more than one response level, with different requirements based
on strict, moderate, or low social distancing levels.
For high-risk activities, states can consider requiring the submission and approval of plans for
reopening.
The CDC has developed additional guidance for businesses.

What else can employers do to support safe reopening?
States may consider encouraging or requiring both public agencies and private employers to report on the
number of known cases of COVID-19, number of workers out for isolation and quarantine, and general
employee absenteeism for illness. These data can help inform population-based surveillance and decision
making on reopening.

Roadmap to Recovery: A Public Health Guide for Governors   25

 For more information:
White House Coronavirus Task Force: Opening Up America Again
Public Health Principles for a Phased Reopening During COVID-19: Guidance for Governors
CDC Interim Guidance for Businesses and Employees
OSHA Guidance on Preparing Workplaces for COVID-19
Seattle Area Mitigation Strategies for Reopening
Overview of State Actions on Business Closure and Personal Movement Restrictions in Response to
COVID-19
NGA Reference Chart on State Essential Business Designations

STEP 10: PREPARE TO REASSESS AND IMPROVE THE PLAN
FREQUENTLY
The stepwise process of a phased reopening requires continuous examination and reevaluation. While
baseline metrics are essential, new circumstances, science, technology, changing epidemiology and
societal considerations will emerge that may necessitate recalibration. States should both communicate
the need for this reassessment and more formally engage in review and improvement over time.

TO LEAD IN ASSESSING AND IMPROVING PLANS FOR REOPENING,
GOVERNORS SHOULD CONSIDER:
Emphasizing the dynamic nature of the process and the need for recalibration.
Running through table-top exercises with state agencies to continuously update and test
the plan.
Continuing to engage stakeholders (such as a taskforce or advisory committee) to inform and
reassess the plan on a periodic basis and identify needed changes to the plan.

KEY OPERATIONAL CONSIDERATIONS:
How are success and failure defined?
From the perspective of reopening the economy, success will be measured by the ability to move from
stage to stage in loosening social distancing requirements. It will also be measured by the long-term
trajectory of recovery, and whether moving between stages is done safely and in a way that improves
public confidence and supports increased economic activity.
From a public health perspective, success includes the ability to recognize the threat of a resurgence
of cases and then acting quickly to prevent significant harm, even if these steps involve a temporary
slowing down of the economy.

26   Roadmap to Recovery: A Public Health Guide for Governors

 From a governance perspective, success requires maintaining public confidence in the state’s response
and inspiring communal action during new challenges and periods of uncertainty.
Characterizing efforts into dichotomous success and failure categories is risky when responding to a
multifactorial natural disaster. Rather, setting expectations for each stage can be a more effective way to
communicate progress.

How can states partner with other entities to assess the framework
States can work closely with CDC experts and ask leading academic institutions to engage key
stakeholders and produce assessments to address specific questions, such as the adequacy of
surveillance, the strength of the public health response, the resilience of the healthcare system, and the
appropriateness of the stages of the reopening. Then, through public input and engagement with key
stakeholders, states can make improvements over time.

Roadmap to Recovery: A Public Health Guide for Governors   27

 CONCLUSION
Communities across the United States continue to
grapple with the unprecedented health and economic
challenges of the COVID-19 pandemic. While a few
states and localities experiencing early outbreaks are
beginning to see cases decline from their peak rates,
others have not yet reached peak infection levels. With
indefinite continuation of community-wide social
distancing neither possible nor desirable, governors
have the opportunity to lead their states into the next
phase of COVID-19 response and recovery by building
the critical public health infrastructure necessary to
identify and stop the spread of the virus, as well as
beginning the process of planning to gradually and
safely reopen social and economic activities.
This guide is intended to provide governors with
tactical information to inform their rapid decisionmaking and set a sustainable pathway toward
recovery. While this document addresses key
public health considerations, governors will also
concurrently need to work to support economic
relief for businesses and individuals impacted by the
COVID-19 crisis. The challenges posed by COVID-19
will continue to evolve, and will require governors to
continually assess and adjust plans as they develop
data-informed responses that suit their own unique
circumstances, challenges and the needs of their
communities.

ACKNOWLEDGMENTS
The National Governors Association Center for Best
Practices (NGA Center) would like to thank the state
officials and other experts who provided input and
feedback on this roadmap, as well as the authors of
the publications and resources cited in this document.

28   Roadmap to Recovery: A Public Health Guide for Governors

CONTRIBUTORS
National Governors Association
Hemi Tewarson
Division Director, NGA Health
Katie Greene
Program Director, NGA Health
Kirk Williamson
Policy Analyst, NGA Health
Association of State and Territorial
Health Officials
Mike Fraser
Chief Executive Officer
Marcus Plescia
Chief Medical Officer
J.T. Lane
Chief Population Health and Innovation
Officer
Other Contributors
Josh Sharfstein
Vice Dean for Public Health Practice and
Community Engagement, Professor of the
Practice,
Johns Hopkins Bloomberg School of Public
Health
Lucy Wilson
Professor & Graduate Program Director
Department of Emergency Health Services
University of Maryland Baltimore County

 APPENDIX A: COMPARISON OF RECOMMENDATIONS ON
APPROACHES TO PUBLIC HEALTH READINESS AND REOPENING
The table below provides insights from the White House Coronavirus Task Force’s Guidelines for Opening Up America
Again as well as six other plans that provide frameworks and recommendations on the capacity needed to consider
reopening state and local economies. While some frameworks identify specific criteria or thresholds that must be met
in order to relax current social distancing measures, others offer more general recommendations for national and state
leaders in building testing, surveillance, contact tracing, and workforce capacity. While this table provides highlights
of each plan, readers should refer to the respective reports for a complete understanding of each framework and their
recommendations.

Organization

White House
Coronavirus
Task Force

American
Enterprise
Institute

Center for
American
Progress

ASTHO &
Johns
Hopkins
Center for
Health
Security

Vital
Strategies:
Resolve to
Save Lives

Duke
Margolis
Center
for Health
Policy

Harvard
Safra Center
for Ethics

Plan or
guidance

Opening Up
America Again

National
Coronavirus
Response: A
Road Map to
Reopening

A National and
State Plan to End
the Coronavirus
Crisis

A National
Plan to Enable
Comprehensive
COVID-19 Case
Finding and
Contact Tracing
in the US

Box It In: Rapid
Public Health
Action Can Box
in COVID-19 and
Reopen Society

A National
COVID-19
Surveillance
System:
Achieving
Containment

Roadmap on
Pandemic
Resilience

Summary

Outlines gating
criteria for three
progressive
phases of
reopening at
the discretion
of governors,
criteria for state
preparedness
and guidance for
individuals and
employers.

Outlines a
national and
regional
approach to
reopen in
four phases.

Identifies six
steps states
should meet to
begin the process
for reopening.

Offers a
national plan
to implement a
comprehensive
system to
conduct contact
tracing for
COVID-19 cases.

Offers a
framework
and key
considerations
for successful
contact tracing.

Provides
recommendation
for establishing
a national
surveillance
system capable
of mitigation and
containment of
COVID-19.

Lays out how
massive testing,
contact tracing,
and social
isolation with
strong supports
can rebuild the
economy in four
phases.

Threshold
for gradual
reopening:
decline in
cases for
each state

Reduction of
flu-like illnesses
AND COVID-like
syndromic cases
for 14 days.

Sustained
reduction in
COVID-19 cases
for 14 days.

Transmission
decreases to a
rate of 20 new
COVID-19 cases
per million
people per day
andSustained
decline in
positive cases.

Not specified.

Not specified.

Refers to the
AEI report.

Not specified.

Threshold
for gradual
reopening:
health
system
capacity
in states

Gating Criteria:
Hospitals can
treat all patients
without resorting
to crisis standards
of care.

Local hospitals
have the ability
to safely treat all
patients without
resorting to crisis
standards
of care.2

Ensure health
care workers
have sufficient
PPE, estimated
to include 300
million N95
respirator masks.

Not specified.

Not specified.

Refers to the
AEI report.

Ensure the health
care system has
the capacity
to safely treat
both COVID-19
patients and
others requiring
care.

AND
Reduction in
documented
COVID-19 cases
OR reduction
in positive
COVID-19 tests
as a percentage
of total tests.

Preparedness:
Hospitals have
sufficient supply
of PPE and critical
medical supplies
for surge AND
ability to surge
ICU capacity.

PPE refers to Personal Protective Equipment.
Ensuring critical care capacity may include hospitals expanding from 2.8 critical care beds to 5-7 per 10,000 adults; expand access to ventilators from 3 to 5-7 ventilators per 10,000
adults; and maintain access to acute care hospital beds of at least 30 per 10,000 adults. Capacity may be adjusted for decrease in cases or met through mobile healthcare infrastructure.
1

2

Roadmap to Recovery: A Public Health Guide for Governors   29

 Organization

Threshold
for gradual
reopening:
testing
capacity in
states

White House
Coronavirus
Task Force

Gating Criteria:
Robust testing
program for atrisk healthcare
workers,
including
emerging
antibody testing.

American
Enterprise
Institute

Test all people
with COVID-19
symptoms.
Estimated national
need for 750,000
tests per week.

Center for
American
Progress

Test those
with COVID-19
symptoms and
their contacts.
Estimated national
need for 2.6 million
tests per day.

ASTHO &
Johns
Hopkins
Center for
Health
Security
Test those
with COVID-19
symptoms
and those who
may have been
exposed.

Preparedness:
Screen and
test those with
COVID-19
symptoms. AND
Test syndromic
and influenza
like illness
indicated
persons.

Additional
recommendations for
expanding
testing
capacity

Guidelines for
Employers:
Develop and
implement
appropriate
policies
regarding
testing.

Same-day, pointof-care testing
widely available
for hospitalized
patients, health
care workers
and workers in
essential roles,
close contacts of
confirmed cases,
and outpatients
with symptoms.

Expand testing
to the sick and
the healthy,
as guided by
conditions on
the ground.

Make serological
testing widely
available.

Serological
testing may be
necessary to clear
people to go back
to work.

Vital
Strategies:
Resolve to
Save Lives

Test those
who have been
hospitalized,
those with
COVID-19
symptoms,
essential
workers, and
close contacts of
confirmed cases.3

Repeated testing
of cases and
contacts to
identify when it
is safe for people
to return to
society.
Accurate, rapid
and low cost
serological tests
should be widely
available.

Duke
Margolis
Center
for Health
Policy

Test those
with COVID-19
symptoms, those
who have been
exposed, or
those at higher
risk of exposure
(e.g. healthcare
workers).

Test those
with COVID-19
symptoms, those
with higher risks
of exposure, as
well as contacts
(including
asymptomatic
contacts).

Estimated national
need of 750,000
tests per week.

Estimated national
need range from
5 to 20 million
per day to 30
to 100 million
per day if initial
interventions do
not succeed.

Rapid diagnostic
testing for
everyone with
symptoms and
their contacts,
those at high
risk for
surveillance
and containment.

Formation
of pandemic
testing board to
support testing
supply and
infrastructure
for deployment.

Develop
surveillance
systems capable
of detecting
outbreaks and
symptomatic
spread.

Endorses
Duke-Margolis
recommendations
for modernizing
disease
surveillance.

Creation of
taskforce to
oversee serologic
testing in the US.

Target for
gradual
reopening:
enhancing
surveillance
systems

Preparedness:
Ensure sentinel
surveillance sites
are screening for
asymptomatic
cases. Sites
should serve
older individuals,
lower-income
Americans,
racial minorities,
and Native
Americans.

Create a
comprehensive
national sentinel
surveillance
system,
coordinated with
local publichealth systems
and health care
providers, akin
to ILINet.

Establish a robust
surveillance
system that
includes testing
of representative
samples of every
county to verify
the number of
new cases.
Conduct
surveillance
testing of a
representative
sample of
households to
monitor disease
spread.

Data collected
during contact
tracing and
surveillance
will need to be
organized and
communicated
effectively both
to state and
national health
authorities.
New technologies
could be
leveraged as
an additional
data source for
surveillance
input.

Conduct ongoing
surveillance at
nursing homes
and hospitals and
among essential
workers.

Harvard
Safra Center
for Ethics

Scale up national
and state-level
health reserves
and integrate
into testing
programs.4

Establish sentinel
testing in select
populations
or high-risk
settings.
Promote the
widespread use
of electronic
standards and
reporting.

Minimum number of tests per day depends on the stage of the epidemic and number of outbreaks, hospitalizations, number of cases and contacts identified, and decisions about the
frequency and extent of testing in nursing homes, hospitals, and essential services.
4
With near-universal adoption of a high-precision tracing technology that allowed immediate, accurate identification of 75% of infected contacts, the number of tests could be further
reduced to 2.5 million per day.
3

30   Roadmap to Recovery: A Public Health Guide for Governors

 Organization

White House
Coronavirus
Task Force

American
Enterprise
Institute

Center for
American
Progress

ASTHO &
Johns
Hopkins
Center for
Health
Security

Vital
Strategies:
Resolve to
Save Lives

Duke
Margolis
Center
for Health
Policy

Harvard
Safra Center
for Ethics

Threshold for
reopening:
contact
tracing

Preparedness:
Ensure that
contacts for
COVID+results
are traced.

Must be able
monitor all
COVID-19
cases and their
contacts before
any reopening.

Ability to conduct
instantaneous
contact tracing
to limit any
outbreaks.

Not specified.

Not specified.

Not specified.

Not specified,
although amount
of required
testing depends
on effectiveness
in tracing
contacts.

Other recommendations
for contact
tracing

Guidelines for
Employers:
Develop and
implement
policies and
procedures for
workforce contact
tracing following
employee COVID+
test.

Trace close
contacts of
confirmed cases
as defined by the
CDC.5

Expand contact
tracing teams of
state and local
health agencies.6

Build capacity
to identify all
contacts of
confirmed cases
and link them to
services.

Massively expand
the public health
workforce and
develop effective
technology to
support contact
tracing.

Endorsement
of Johns
Hopkins/ASTHO
recommendations
for hiring
100,000 new
contact tracers.

Rapidly hire a
large workforce
estimated at
100,000 contact
tracers (paid
or voluntary)
nationally.7

Employ
approximately
100,000 contact
tracers nationally.

Expand public
health workforce
to trace close
contacts,
supported by new
technology and
communitylevel
collaborations.

Infected
individuals
should be
isolated at home
when possible.

Support for
quarantined
and isolated
individuals in
the form of job
protections,
material support,
and access to
healthcare.

Surge the public
health workforce
to conduct case
finding and
contact tracing.

Leverage mobile
technologies to
notify people who
were proximate
to a person with
COVID-19.

Enable rapid
reporting to
public health
authorities
through this
workforce and
electronic data
sharing from
providers and
labs.

Recommendations for
isolating
infected
individuals

Guidelines for
Employers:
Monitor
workforce
for indicative
symptoms.
Do not allow
symptomatic
people to
physically return
to work until
cleared by a
medical provider.

Confirmed
case should be
isolated at home,
in a hospital, or
(voluntarily) in
a local isolation
facility for at
least seven days.
Field hospitals,
dormitories,
hotels, and
military
barracks may be
repurposed.
Technology
approaches
can enable and
support isolation
and quarantine
efforts (e.g.,
home isolation
enforced with
mobile GPS
technology).

Use technology to
identify contacts,
track symptoms
and aggregate
data.

States should
establish centers
to isolate
confirmed and
suspected cases
on a voluntary
basis.9
Fund living
and treatment
support centers
to support
individuals
isolated at home.

Isolate infected
individuals at
home or, as
necessary and on
a voluntary basis,
in healthcare
facilities or
dedicated
isolation
facilities.

Use trusted
leaders and
popular figures
to promote
compliance.

Provide basic
services for those
who must remain
in isolation,
including food
and shelter if
they cannot
safely go home.
Prevent
transmission
in hospitals by
rapidly finding
and effectively
isolating all
infected patients.
Increase
compliance
by providing
stipends to
compensate for
lost wages, and
child or elder
care.

State and
local health
departments
should, with
federal funding,
make local
facilities for
isolation and
quarantine
available to
individuals who
need them.

Use of peerto-peer
warning apps
with maximal
privacy and data
protection.

CDC defines close contact as those who were within 6 feet of a COVID-19 case for a prolonged period of time; had direct contact with infectious secretions of a COVID-19 case.
Manual contact tracing by itself will not be effective in stopping transmission, and technological solutions will be necessary for instantaneous contact tracing.
7
Based on the average pay for a community health worker of $17 an hour, the potential overall need for funding for a cadre of 100,000 contact investigators, absent a huge number of
unpaid volunteers, would amount to approximately $3.6 billion.
8
People awaiting test results should be advised to quarantine until their results are returned.
9
Individuals who test positive for COVID-19 and individuals who have a fever should be isolated in designated, repurposed hotels, college dormitories, or other facilities at government
expense. States must also provide hotels for front-line health care workers so that they can protect their families
Roadmap to Recovery: A Public Health Guide for Governors   31
5

6

 Organization

Recommendations for
quarantining
exposed
individuals

White House
Coronavirus
Task Force

None specified.

American
Enterprise
Institute

Center for
American
Progress

Close contacts of
confirmed cases
as defined by the
CDC should be
quarantined and
monitored daily
for 14 days.

None specified,
although support
centers would
also serve
suspected cases
in quarantine.

People awaiting
test results
should be advised
to quarantine
until their results
are returned.

ASTHO &
Johns
Hopkins
Center for
Health
Security

Vital
Strategies:
Resolve to
Save Lives

Quarantine
exposed
contacts in
their homes (or
other dedicated
facilities, if home
is not an option)
for 14 days
after their last
exposure to the
case, monitoring
for symptoms
until diagnostic
results show they
are not infected.

Provide ready
access to
telehealth
services and
care for those in
quarantine, when
needed.10

None specified.

None specified.

Monitor
international
travelers.

Other
recommended
mitigation
measures

For Individuals:
Continue to
practice good
hygiene (e.g.
wash hands,
sneeze or cough
into tissue,
strongly consider
face coverings in
public) and stay
home when sick.
Maintain physical
distancing, avoid
large groups,
minimize nonessential travel
according to
phase guidelines.
Precautions
should be taken
for vulnerable
individuals.
For Employers:
Develop and
implement
appropriate
policies regarding
social distancing
and protective
equipment,
temperature
checks, testing,
isolating, and
contact tracing,
sanitation,
disinfection of
high-traffic
areas and
business travel.
Implement other
appropriate
guidance
according to
phase.

Maintain physical
distancing
precautions
after reopening
including
widespread
teleworking,
maintaining
hand hygiene
and respiratory
etiquette, wearing
a mask in
public, regularly
disinfecting hightouch surfaces,
and initially
limiting social
gatherings to
fewer than 50
people.

Physical
distancing must
remain until
herd immunity is
achieved.
Employers must
continue to allow
telework to the
extent possible.

Duke
Margolis
Center
for Health
Policy

Harvard
Safra Center
for Ethics

Contacts of
confirmed
cases should
be quarantined
rapidly either
at home or in
local facilities
for those who
need it.

Support for
quarantined
and isolated
individuals in
the form of job
protections,
material support,
and access to
healthcare.

With federal
support, make
local facilities
for isolation
and quarantine
available to
individuals who
need them.

Contacts
of COVID+
individuals would
be repeatedly
tested rather
than quarantined.

Utilize a range of
other electronic
data systems,
once available,
for a more
sophisticated and
effective disease
surveillance
system.

Milder mitigation
measures would
remain in place,
such as limits on
mass gatherings
and reduced
density on public
transportation.

Transportation
protections
(physical
distancing,
sanitizing) must
remain in place.
Ban gatherings
of more than 50
people.

Implement
physical
distancing
measures for
schools and
businesses.
Maintain a
higher level of
social distancing
for vulnerable
populations.

An emerging best practice is testing quarantined contacts for presence of the virus on two occasions toward the end of their quarantine period and obtaining negative results before
releasing them from quarantine.
10

32   Roadmap to Recovery: A Public Health Guide for Governors

 Organization

White House
Coronavirus
Task Force

American
Enterprise
Institute

Center for
American
Progress

ASTHO &
Johns
Hopkins
Center for
Health
Security

Vital
Strategies:
Resolve to
Save Lives

Duke
Margolis
Center
for Health
Policy

Harvard
Safra Center
for Ethics

Timeline for
current social
distancing
measures

Movement from
each phase occurs
when there is
no evidence of a
rebound and the
gating criteria is
met.

None specified.

A stay at home
policy for a
minimum of 45
days starting
April 5, with high
compliance rates.

None specified.

None specified.

None specified.

Widespread
testing should be
in place by early
June.

Criteria for
reinstating
social
distancing

Governors may
need to restart or
return to earlier
phases based
on severity of
conditions.

If a substantial
number of cases
cannot be traced
back to known
cases, if there
is a sustained
rise in new cases
for five days, or
if hospitals in
the state are no
longer able to
safely treat all
patients.

Cautions states
to meet all the
criteria to avoid
a second wave of
the epidemic.

None specified.

None specified.

None specified.

If interventions
do not succeed,
and we have
not developed
capacity to test
at much higher
levels in work
and school
community
settings (e.g.,
30 to 100 million
a day).

Roadmap to Recovery: A Public Health Guide for Governors   33

 APPENDIX B: IDENTIFYING KEY PUBLIC HEALTH AND
PREPAREDNESS METRICS FOR A STATEWIDE MITIGATION
DASHBOARD
Steps 7 and 8 of the Roadmap advises governors to create a preliminary framework and identify
measures for assessing a state’s readiness to begin a gradual re-opening of the economy. Operational
considerations in these steps include outlining key metrics for inclusion in a statewide mitigation
dashboard, as well as preparedness plans that states may put in place to protect key populations and
areas from COVID-19 transmission during a gradual relaxing of social distancing measures.
The following is a list of potential metrics compiled from the White House Coronavirus Task Force’s
Guidelines for Opening Up America Again and other sources that states may consider using as part of
their “Mitigation Dashboards.” Although states will identify metrics based on their own unique needs
and data-sharing capabilities, the following list provides options for understanding trends and changes
in COVID-19 transmission, as well as critical information on the state’s preparedness on testing, health
system capacity, and other public health functions as social distancing is relaxed.

POTENTIAL STATE METRICS FOR MITIGATION
Case Identification and Trends
Are COVID-19 cases decreasing or increasing? Decreasing positive cases means mitigation is working and
should be continued; increasing cases mean transmission still occurring.
GOAL: Decreasing rates of positive cases for at least 14 days.*
METRIC: # positive cases 
METRIC: # cases overall 
GOAL: Decrease in cases overall for a minimum of 14 days.
METRIC: Trend in # of cases. States may want to monitor at 3, 7, 10, 14, 21, and 30-day
trends.
GOAL: Decrease in deaths from COVID-19 for a minimum of 14 days.
METRIC: # of COVID-19 related deaths overall States should consider monitoring deaths
by age group, by race/ethnicity. States should consider feasibility of monitoring by facility
such as hospital, nursing home, long-term care facility, prison, etc.
Decreasing rates of influenza-like illness (ILI) may mean mitigation is working and should be continued;
increasing cases means transmission may still be occurring.
GOAL: Decreasing reports of ILI for at least 14 days.*
METRIC: # of outpatient visits for ILI. States may want to monitor at 3, 7, 10, 14, 21, and
30-day trends.
GOAL: Decrease in COVID-19 like syndromic cases for at least 14 days.*
METRIC: # of outpatient visits for COVID-19 like syndrome for at least 14 days. States may
want to monitor at 3, 7, 10, 14, 21, and 30-day trends.

Roadmap to Recovery: A Public Health Guide for Governors   34

 Point of Care Testing Results and Testing Capacity
Does the state have the capacity to test those who need to be tested, and do it safely and quickly? Is the
testing being conducted finding fewer positive cases, which would indicate less transmission, or more
positive cases, which would indicate more spread, as a percentage of all tests being conducted? Is the
state addressing potential differences in testing by different groups?
GOAL: Decrease in “percent positive” tests over a 14-day period.*
METRIC: % of positive tests as a percentage of total tests
METRIC: # of tests conducted
METRIC: # of positive tests of all tests conducted
GOAL: All testing sites can screen for asymptomatic cases.*
METRIC: # of sentinel testing sites
METRIC: # of sentinel testing sites that can screen for asymptomatic cases
GOAL: Sentinel testing sites operate in key locations serving older individuals, lowerincome individuals, racial and ethnic minorities including Native Americans.*
METRIC: # of sentinel testing sites operating in locations that serve older
individuals, lower-income individuals, and racial and ethnic minorities including
Native Americans.
Do states have what they need to meet the demand for testing and to quickly report test results?
GOAL: Decrease in average time to report COVID-19 test results.
METRIC: Time from specimen to result reported (hours, days).
GOAL: State testing capacity, including equipment, supplies, reagents, and staffing meets
the demand for testing.
METRIC: # of labs reporting need for additional equipment, supplies, reagents, and
staffing.

Health Care Facilities and Health Care Worker Capacity
Does the state have the health care facility capacity and staffing needed to safely treat individuals with
COVID-19 and to protect other patients and health care workers from infection?
Do hospital systems have the capacity to treat a surge in cases and are they able to care for COVID-19
patients using recommended guidelines and protections (usual standards of care)?
GOAL: Hospitals can quickly and independently supply sufficient PPE and critical medical
equipment and can surge intensive care unit (ICU) capacity.*
METRIC: % of hospitals that can handle a defined increase in patient volume from  
current census with sufficient PPE and adequate ICU capacity.
GOAL: Hospitals can care for all patients without using crisis standards of care.*
METRIC: % of hospitals that care for all patients without using crisis standards of
care.
METRIC: % of hospitals reporting sufficient PPE to treat COVID-19 patients and  
protect health care workers.

3 5   Roadmap to Recovery: A Public Health Guide for Governors

 Can health care facilities test and protect all health care workers from COVID-19 infection?
GOAL: Ensure robust testing programs for at-risk health care workers.*
METRIC: # of hospitals that have a testing program in place for health care workers
GOAL: Health care worker COVID-19 infections are at or close to zero.
METRIC: % of health care workers testing positive for COVID-19 is at or close to
zero.

Public Health System Capacity
Does the state have the public health capacity and staffing needed to safely identify individuals and
their contacts who may have been exposed to COVID-19 and to prevent transmission of COVID-19? Are
case tracing and disease investigation activities sufficient to contain outbreaks of COVID-19 quickly and
safely?
GOAL: The public health system has the ability to trace contacts of every COVID-19 positive
case within the state.*
METRIC: % of public health departments reporting sufficient capacity to perform
contact tracing of every COVID-19 positive case in their state.
GOAL: The public health system has sufficient capacity to contact at least 90% of all elicited
contacts.
METRIC: % of public health departments reporting sufficient capacity to contact at
least 90% of all elicited contacts.
GOAL: All symptomatic contacts are tested within 12 hours.
METRIC: % of public health departments that report all symptomatic contacts are
tested within 12 hours of contact.
GOAL: The public health system has sufficient capacity to test individuals with ILI-like or
COVID-19 like symptoms for COVID-19 and to trace their contacts.*
METRIC: % of public health departments that report all symptomatic contacts are
tested  within 12 hours of contact.
Can the public health system test and protect all public health workers from COVID-19 infection?
GOAL: Every public health agency has a robust testing program in place for public health
workers.
METRIC: # of public health agencies that have a testing program in place for public
health workers.
GOAL: Public health worker COVID-19 infections are at or close to zero.
METRIC: % of public health workers testing positive for COVID-19 is at or close to
zero.

Roadmap to Recovery: A Public Health Guide for Governors   36

 Ten Key Metrics To Consider
1.

# of positive cases, 14-day trend

2.

# individuals with ILI symptoms, 14-day trend

3.

# of individuals COVID-19 like syndrome cases, 14-day trend

4.

# of “percent positive” tests, 14-day trend

5.

% of testing sites can screen for asymptomatic cases

6.

% of sentinel testing sites operate in key locations caring for vulnerable populations

7.

% of hospitals that can handle a doubling of patient volume from current census in one day
with sufficient PPE

8.

% of hospitals that can care for all patients without using crisis standards of care

9.

% of health care facility has a robust testing program in place for health care workers

10.

% of public health agencies with sufficient contact tracers and related staffing and equipment
to support case investigation of every COVID-19 positive case identified in their State

3 7   Roadmap to Recovery: A Public Health Guide for Governors

 PREPAREDNESS PLANS IN PLACE FOR REOPENING
The state has plans in place to protect workers returning to work from becoming infected with COVID-19
and to prevent transmission of COVID-19 if physical distancing guidelines and other mitigation efforts
are reduced. Plans for key industries and areas are developed and shared broadly. Does the state have the
plans it needs to start a gradual return to work?
Essential Plans in Place to Reopen
The state has plans that can be immediately implemented for the following
1.

Protecting the health and safety of workers in critical industries*

2.

Protecting the health and safety of those living and working in high-risk facilities (e.g., senior
care facilities)*

3.

Protecting employees and users of mass transit*

4.

Monitoring conditions and immediately responding to increases in transmission rates or
outbreaks*

5.

Advising the public regarding social distancing and face coverings*

6.

Protecting employees and the public in essential businesses and public services including law
enforcement, fire, emergency medical services, and public health

7.

Protecting at-risk individuals such as those experiencing homelessness and racial and ethnic
minorities

8.

Protecting employees and customers of non-essential businesses and public services

9.

Protecting workers and students in educational facilities, including schools and universities

10.

Protecting the health and safety of workers in other congregate settings including group
housing, places of worship, correctional facilities, etc.

11.

Protecting the health and safety of those using public parks, beaches, etc.

12.

Protecting travelers, visitors, and employees in the hospitality and tourism sector

METRIC: Plan in place for each of the areas listed above.
* Indicates a goal or plan that is included in the White House Coronavirus Task Force’s Guidelines
for Opening Up America Again. These goals and plans are mentioned as “Proposed State or Regional
Gating Criteria” and “Core State Preparedness Responsibilities.” Additional metrics in this document
come from other Center for Disease Control and Prevention (CDC) planning guidance, consultation with
preparedness experts and public health professionals, and reopening guidance developed by several other
organizations including Resolve to Save Lives, the Association of State and Territorial Health Officers, the
Johns Hopkins Center for Health Security and the Johns Hopkins University Bloomberg School of Public
Health.

Roadmap to Recovery: A Public Health Guide for Governors   38