Basics of developing a COVID-19 reopening roadmap, a systematic scoping review of reopening roadmaps

Background: The necessity of easing pandemic restrictions is explicit. Due to the harsh consequences of lockdowns, governments are willing to nd reasonable pathways to reopen their activities. Methods: To nd out the basics of developing a reopening roadmap, on 6 th -10 th August 2020, we conducted a systematic search on Pubmed, Scopus, Embase, and Web of Science, but no roadmap was found. Then, we manually searched Google to review the grey literature. Two independent authors extracted the data, and the senior author solved the discrepancies. Results: According to the search strategy, nally, sixteen roadmaps were included. Data categorized into four sections: principals, general recommendations for individuals, health key metrics, and in-phases strategy. The number of phases or stages differed from three to six, with a minimum of two weeks considered for each one. Health key metrics were categorized into four subsets: sucient preventive capacities, appropriate diagnosis capacity, appropriate epidemiological monitoring capacity, and sucient health system capacity. These metrics were used as the criteria for progressing or returning over the roadmap, which guarantees a roadmap's dynamicity. Noticeably, few roadmaps didn’t mention these criteria that may alter the dynamicity of their roadmap. When some areas face new surges, the roadmap's dynamicity is essential, and it is vital to describe the criteria to stop the reopening process and implement the restrictions again. Conclusions: Providing evidence for policymaking about lifting the COVID-19 restrictions seems to be missed in the literature, should be addressed more, and further studies are recommended.


Introduction
Late in 2019, severe acute respiratory syndrome-related novel coronavirus 2 (SARS-CoV-2), known more commonly as COVID-19, appeared. Despite extensive containment measures, this virus continued to spread rapidly throughout Page 3/28 Also, isolation and restricting people to their homes have negatively affected many individuals' mental and physical health (6). In a study on mental health during the COVID-19 outbreak, nearly half of the participants reported suffering from a new-onset depression (7). Furthermore, another study suggests that quarantine is responsible for a signi cant reduction in physical activity and increased emotional eating, which may increase the risk of many noncommunicable diseases (8).
Due to these consequences, governments are willing to lift or at least ease the coronavirus lockdown earlier; however, this decision could refuel the pandemic and making the situation even more complicated.
To slow the COVID-19 spread, these attempts to lift or ease the isolation should be postponed until its transmission has measurably been slowed down, and the healthcare system is capable of managing the outbreak. Reopening early could cause resumption of the outbreak; reopening later could lead to socioeconomic tribulations. Unfortunately, appropriate conditions required for the timely reopening of the society have not been identi ed so far.
Based on a preliminary search in PubMed and Cochrane Database of Systematic Reviews, there is no overview regarding reopening roadmaps. In this review, we de ned the basics for developing a reopening roadmap in response to COVID-19 related lockdowns and closures. The ndings will help the local and world health authorities take proper actions toward developing a reopening strategy based on existing evidence.

Research question:
What is known from literature about the basics and foundation of a reopening roadmap implemented by countries or states to ease the COVID-19 restrictions?

Methods
The present review was conducted and reported based on the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) statement (9).

Inclusion and exclusion criteria:
We included the roadmaps designed by countries and states to ease the COVID-19 general lockdowns. We excluded those not published in English and those focused on reopening strategies specialized for certain activities, such as school reopening, restaurant reopening, etc.
Search strategy: As illustrated in Fig.1, we performed a multi-step search strategy. An initial and limited search was done on Pubmed to find reopening roadmaps and related papers, but no paper was found. Therefore, we repeated our search via Google search engine; some roadmaps were retrieved. We analyzed the keywords in the title and introduction of these papers and discussed with all authors to identify the most related and comprehensive terms. During 6 th -10 th August 2020 and based on the previous step Page 4 /28 results, two authors separately searched Pubmed, Scopus, Embase, and Web of Science systematically; Google search engine was also reviewed manually to explore the grey literature. We used the following terms in our search ((COVID-19 OR COVID19 OR SARS-Cov2 OR 2019-nCov) AND (Reopening OR Re-opening) AND Roadmap). Table 1 shows the search strategy for Pubmed and Web of Science; the same strategy was expanded to all other included databases. Again, no roadmap was found in these major databases, but grey literature gave us 39 roadmaps. There was no duplication in roadmaps. Of these, 23 roadmaps were excluded according to the exclusion criteria, and finally, 16 roadmaps met the eligibility criteria and included for data extraction Data items and data extraction process: The following items were extracted from included roadmaps: Country or state, time of publishing, the principals, general recommendations for individuals, health key metrics and indicators, number of phases or stages, the time considered for each phase or stage, criteria of progressing to next phase or returning to the previous phase. A data extraction form was designed in Excel, and two independent authors extracted the data. The senior author resolved discrepancies.

Synthesis of results:
We summarized, categorized, and tabulated the extracted information. In Table 2, the results are summarized in details. As seen, protecting vulnerable and high-risk groups within the society is the most frequent point in the roadmaps (six roadmaps).
An increase in testing capacity and contact tracing are also noticeable in four roadmaps. Moreover, the need for science-driven and evidence-informed decision making was an important topic (four roadmaps). The proportionality of decisions to impose the lowest economic risks while protecting population health was also mentioned four times.
Transparency and being clear was also repeated three times. It is highly likely to fail if the state cannot gain public trust. In such a scenario, being honest and transparent can help to increase social cohesion.
In each reopening phase, preventive measures such as physical distancing should be followed strictly, especially in childcare centers, schools, bazaars, and workplaces (four roadmaps). In three roadmaps, it was mentioned that the health-related resources should surge.
Moreover, only in the European Council's roadmap, the need for international collaboration with other countries (but still with other countries of the European Union) was mentioned. In this proposed guideline, all members should observe the protocols simultaneously to increase the efficacy of actions and decrease political conflicts within the commission. They believed that lifting the restriction should be consulted a priori, and Europe should act integratively. Knowledge and resources (protective suits, masks, and ventilators) should be shared with the most vulnerable members. Without a doubt, it is believed that all countries/states, mostly those nearby, should work more cohesively to prevent the spread of disease.
People should be educated to live with COVID-19, considering new norms, which are clearly mentioned in Nashville's roadmap. The role of public health education has not been taken seriously in other roadmaps. As a result of this, we highlight the role of education and further adaptation. The last and by no mean the least is to be flexible enough to adapt to changing conditions in the case of resurgence or other unexpected issues (Ontario).
The others are provided in detail in Table 2.
[Please see the supplementary files section to view table 2.]

The general recommendations for individuals
Almost all these roadmaps mentioned hand hygiene, using either water and soap or alcohol-based sanitizers. In the roadmap of California, the authors did not specifically mention practicing good hand hygiene but recommended coughing or sneezing etiquette. According to the Centers for Disease Control and Prevention (CDC), one essential part of this etiquette is performing good and suitable hand washing (25). Therefore, we implied that the authors recommended this, as well. In contrast to the others, six roadmaps such as Nashville and Nevada did not directly mention hand washing. The roadmap from Indiana believed that close contact between people in a confined place is an essential route of transmission of the viruses. Therefore, this roadmap, along with the others from Ontario, UK, Shasta County, Ireland, Nevada, Connecticut, Nashville, and Queensland, firmly Page 7/28 recommended limiting outside gatherings. Six roadmaps also mentioned the importance of travel restrictions; meanwhile, some believed that passengers should be quarantined for fourteen days.
Some people are more vulnerable to COVID-19. Individuals older than 65 or patients with diabetes mellitus, chronic lung disease, moderate to severe asthma, and severe heart conditions are some of these vulnerable populations. Immunocompromised people, through either cancer treatment, smoking, any organ transplants, genetic or acquired immune deficiencies, and/or the prolonged usage of corticosteroids, may also experience more severe and complicated disease (29). More than half of these roadmaps (nine out of 16) mentioned supporting these most vulnerable patients.
As illustrated in Table 3, general recommendations noted for individuals in reviewed roadmaps were tabulated.

Open up
America again 11 10 9 12 5 9 9 6 6 9 The etiquette consists of providing tissues and no-touch receptacles for used tissue disposal, providing conveniently-located dispensers of alcohol-based hand rub; where sinks are available, ensure that supplies for hand washing (i.e., soap, disposable towels) are consistently available § with soap and water, or using an alcohol-based sanitizer if soap and water are not available * 2 meters (6 feet) in public.
** The typical signs and symptoms are cough, fever, dyspnea, and diarrhea. Consider atypical ones as well. Health key metrics for reopening strategy According to data extracted from the 16 reviewed roadmaps, the key metrics used for monitoring the reopening process could be categorized into four subsets: sufficient preventive capacity, appropriate diagnosis capacity, appropriate epidemiological monitoring capacity, and sufficient health system capacity.
The preventive capacity consists of optimizing the supply of personal protective equipment (PPE), especially for those at high risk and those on the front line (30,31). Furthermore, there should be the capacity to implement protocols ensuring appropriate safeguards for each sector reopened. The second subset relates to appropriate diagnosis capacity, including large-scale testing capacity combined with contact tracing (32). Based on its strategy, each territory should continue to increase the amount of available testing and be affordable for all population groups, including opportunities to obtain free tests. Ensuring adequate testing and tracing capacity is necessary to allow policymakers to oversee high-risk populations and modify their planning for reopening each sector.
Besides this large-scale expansion of testing, early testing should also include amongst high-risk congregate settings, including nursing homes and assisted living facilities, prisons, and dormitories.
Key metrics related to appropriate epidemiological monitoring capacity and active surveillance also play an important role in the designation of reopening strategy (33). These criteria consist of a vast range of critical metrics, including the trend of positive testing, hospitalization, and death rate.
Policymakers must actively monitor the pandemic's epidemiological status to step back in the case of resurging viral rates. A sustained downward, or at least not being upward of the trend in these metrics is critical to allow the reopening process to keep going forward. The last set of key metrics is categorized under sufficient health system capacity, includes sufficient capacity for hospital floor reopening steps and the contacts between the populations are rising, there is a demand for the territory to provide sufficient health care. Furthermore, the capacity to support those in isolation/quarantine is needed (34). These health metrics mentioned in the reviewed roadmaps are tabulated in Table 4.
These metrics should be assessed closely and carefully to prevent the infection's resurge and help authorities determine the proper pace of the reopening. Although all these metrics are important and cannot be ignored during planning for reopening, some metrics may be more considerable in the design of the reopening roadmap. activities (38,39). In order to reach dynamicity, the health authorities should precisely determine the criteria of when progress to the next phase and when returning back and stop the reopening process.
Most of the roadmaps used the health key metrics mentioned in the previous section as the criteria for moving forward. But the criteria of moving backward to the previous phase as a response to a new surge was not established well in some roadmaps. Table-4 illustrated the detail of such criteria.
In the reviewed roadmaps, the number of reopening phases differed from three to six. However, in general, the reopening stages that have been mentioned in released roadmaps can be categorized into three phases. In the first one, which is mostly referred to as the supporting phase, non-essential workplaces, recreational centers, and public places, as well as restaurants, would be closed.
Furthermore, social gatherings and workplace staff were restricted. Limited working hours and frequent working shifts are of other recommendations in this phase. In the next class, restrictions will be more lift up. Social gatherings and workplace staff will be more allowed. Finally, the condition is approximately, back to normal or to a new normal in the last phase.
Interestingly, in some roadmaps, such as American Enterprise Institute designed recovery roadmap, there is an extra phase for rebuilding readiness against the next pandemics. The minimum time considered for a phase was two weeks, which is as same as the SARS-CoV2 incubation period. More details can be found in Table 5. Social distancing, using a mask/ facial covering to reduce the spread of respiratory droplets, and washing hands were the essential preventive actions recommended for individuals. A few roadmaps didn't mention anything about general recommendations for individuals that should be addressed in any reopening roadmaps.
Health key metrics that pointed out in the roadmaps were categorized into four subsets; su cient preventive capacities such as personal protective equipment, appropriate diagnosis capacity including extending testing and contact tracing capacity, appropriate epidemiological monitoring capacity including the downtrend trajectory of COVID-19 positive cases and hospitalized patients, and su cient health system capacity including hospital beds and ventilators in order to be resilient in facing the surges and next phases of the pandemic.
All roadmaps described their in-phases strategy. The phases can be categorized into three signi cant steps.
However, the number of phases differed from three to six, with a minimum of 2 weeks considered for each phase.
Dynamicity is the crucial key for developing a roadmap is missed in some roadmaps by setting a rigid timeline.
Based on the health key metrics, most of the roadmaps noted when progressing to the next phase and when returning, while some of them didn't focus on the criteria of returning to the previous phase. Now when some areas are facing a new surge in the number of new cases and increasing the death tolls, it is vital to precisely describe the criteria to stop the reopening process and implement the restrictions again, as well as the criteria for progressing to the next phases.

Limitations
Due to the scarcity of proper evidence regarding this topic in the literature, mainly in major databases, we had to search via Google search engine manually. It may alter the searching systematically as required in a scoping review.
Nevertheless, we believe that these pieces of evidence can assist the global and local health authorities in taking proper action plans regarding lifting the restrictions.

Conclusion
In the second half of October 2020 and during the reopening of activities, when most countries are facing new surges regarding COVID-19 new cases and death tolls, it seems that providing further evidence-based information concerning reopening strategies is crucial. The present review aimed to provide an overview of the basics for developing and designing an in-phases reopening strategy by reviewing the current roadmaps. We believe that the results can help local and world health policymakers taking proper action plans to minimize the consequences of society reopening.  Preferred reporting items for systematic reviews and meta-analyses (PRISMA) ow diagram of the study

Supplementary Files
This is a list of supplementary les associated with this preprint. Click to download. Table2.docx