An overview of basics for developing a reopening roadmap amid COVID-19 pandemic, a suggestion for the world

The necessity of easing pandemic restrictions is apparent, and due to the harsh consequences of lockdowns, governments are willing to nd a rational pathway to reopen their activities. To nd out the basics of developing a reopening roadmap, we reviewed 16 roadmaps. The most notable ndings are as following: Protecting the high-risk groups, increasing testing and contact tracing capacity, making decisions scientically, and making the decisions to impose the lowest risks to the economy were the most principles mentioned in the roadmaps. Social distancing, using a face-covering mask, and washing hands were the necessary preventive actions that were recommended for individuals. Health key metrics pointed out in the roadmaps were categorized into four subsets; sucient preventive capacities, appropriate diagnosis capacity, appropriate epidemiological monitoring capacity, and sucient health system capacity to be resilient in facing the surges and next phases of the pandemic. All roadmaps describe their in-phases strategy in three major steps, with a minimum of two weeks considered for each phase. Based on the health key metrics, most of the roadmaps noted when progressing to the next phases, while some of them did not focus on the criteria of returning to the previous phase; which may alter the dynamicity of a roadmap. We aimed to review reopening roadmaps implemented for activities reopening amid COVID-19. Protecting high-risks, increasing diagnostic capacity and making decisions scientically were common principles. Metrics categorized into four subsets; sucient preventive, diagnostic, epidemiological, health system capacity. Three major phases with minimum time of two weeks for each phase. Dynamicity was altered in some due to lack of returning back criteria.


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 the world, making it a public health emergency of international concern as the World Health Organization (WHO) declared a pandemic on March 11, 2020(1).
The COVID-19 outbreak has affected everyone. Signi cant consequences of social distancing measures have temporarily changed the typical structures of daily life, such as work, school, sport, and entertainment. It seems that until a treatment or vaccine for COVID-19 is available, life will not return to normal.
Fighting this virus is like an all-round battle that involves several stages. If we cannot move from one stage to the next, the situation will not normalize, and we will kneel in other areas, including economics. For instance, the United Kingdom (UK) and Ireland have experienced unprecedented nancial problems, including raising the unemployment rate and falling of Gross Domestic Product (GDP), which is expected to be seen worldwide (2,3). According to a report by Institute for scal studies (4), lockdown will disproportionately hit the community members; Employees aged under 25, females, and low earners are more likely to be affected, and lost future earnings potential is more remarkable for young people. What needs to be taken seriously is that the longer shutdown measures stay in place, the more signi cant scarring will face long-term economic indexes.
Apart from the nancial aspects of lockdown strategies, public health care, and emergency care delivery has also been affected by the pandemic. Heart attacks and strokes, routine immunization programs, screening activities, and treatment for non-communicable diseases like cancer and diabetes face new challenges, like fear, misinformation, and limitations on movement have disrupted delivery of such services (5).
As well, isolation and restricting people to their homes has negatively affected many individuals' mental and physical health (6). A study on mental health during the COVID-19 outbreak, near 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 ne 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. Methods strategy. Two independent reviewers extracted the mentioned items, and the senior author solved discrepancies. The results were summarized and tabulated to be satisfactory.

Results
The principles of roadmaps OF 16 mentioned roadmaps, four did not mention any point about the principles of developing the roadmaps, seven roadmaps clearly mentioned their principles, and of the remaining ve, the principles were not clear, so the authors implied the doctrines of the roadmaps.
In table1, the results are summarized with 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 phase of reopening, 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 roadmap of the European Council, 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 e cacy of actions and decrease political con icts 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 the roadmap of Nashville. 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 exible enough to adapt to changing conditions in the case of resurgence or other unexpected issues (Ontario).
The others are provided in detail in table 1. 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 speci cally 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 (24). 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.
Except for the "Open up America again" roadmap, others emphasized maintaining proper social distancing (about two meters or six feet in public). According to the Connecticut roadmap, roommates and suitemates were considered, as family units, therefore among them; social distancing was not necessary.
COVID-19 has a wide range of clinical manifestations affecting people of all ages. Typical symptoms include cough, fever, and dyspnea; however, gastrointestinal symptoms and anosmia may occur (25)(26)(27). All individuals should be aware of clinical manifestations of COVID-19 and stay home if they feel sick and seek medical consults with quali ed medical staff. Five roadmaps recommended being vigilant to signs and symptoms of the disease and nine roadmaps recommended staying at home. The roadmap from Ireland strongly suggested that individuals should keep informed about the pandemic status, support, and follow informed medical advice.
The roadmap from Indiana believed that close contact between people in a con ned 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, rmly 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 de ciencies, and/or the prolonged usage of corticosteroids, may also experience more severe and complicated disease (28). More than half of these roadmaps (nine out of 16) mentioned supporting these most vulnerable patients.
As illustrated in Table-2, general recommendations noted for individuals in reviewed roadmaps were tabulated.
Total 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: su cient preventive capacity, appropriate diagnosis capacity, appropriate epidemiological monitoring capacity, and su cient 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 (29,30). Furthermore, there should be the capacity to implement protocols ensuring appropriate safeguards for each sector reopened. The second subset relates to appropriate diagnosis capacity, which includes large-scale testing capacity combined with contact tracing (31). Each territory, based on its strategy, should continue to increase the amount of available testing and be affordable for all population group, including opportunities to obtain free tests. Ensuring adequate testing and tracing capacity is necessary to allow policymakers to oversee high-risk population and modify their planning for reopening of 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 (32). 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 epidemiological status of the pandemic 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 are categorized under su cient health system capacity, includes su cient capacity for hospital oor and critical care beds, ventilators, and healthcare system readiness. As society moves forward in the reopening steps and the contacts between the populations are rising, there is a demand for the territory to provide su cient health care. Furthermore, the capacity to support those in isolation/quarantine is needed (33). These health metrics mentioned in reviewed roadmaps are tabulated in Table-3.
These metrics should be assessed closely and carefully to prevent the resurge of the infection 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. Antibody detection capacities · Sustained reduction in hospitalizations and patients in intensive care · Access to pharmaceutical products required in intensive care units · The reconstitution of stocks of equipment · Access to care in particular for vulnerable groups · The availability of primary care structures as well as su cient staff with appropriate skills to care for patients discharged from hospitals or maintained at home and to engage in measures to lift con nement In-phases strategy Planning a dynamic pathway to reopening necessitates breaking the roadmap into several successive stages. To better decision making, different aspects of lockdown or reopening should be addressed; otherwise, neither lockdown nor reopening would bene t. This staging should be dynamic, thorough, executable, and innovative (34,35). Dynamic means that moving back and forth through the stages depends on the current COVID-19 situation at the time; the prevalence should continuously be monitored via the aforementioned key public health metrics (35,36). Unfortunately, this dynamicity has been missed in some designed roadmaps. For example, Queensland's roadmap has determined the exact day and even hour of prompting to the next stage, and such approaches lack surveillance and would fail to prevent the resurging of SARS-CoV-2 infection while resuming socioeconomic activities (37,38). 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 rst 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, in the last phase, the condition is, approximately, back to normal or to a new normal.
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-4.

Discussion
Of the 16 reviewed roadmaps, most of them directly or indirectly mentioned the principles of developing their roadmap. Protecting the vulnerable and high-risk groups, increasing testing capacity and contact tracing, making decisions based on scienti c evidence, and making the decisions to impose the lowest risks to the economy were the most principles mentioned. Principles that can shed light on the monitoring of a roadmap have not been mentioned in four roadmaps; the fact that can raise attention in a way that a roadmap without speci c principles is like a building without foundation.
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.

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 about 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 to take proper action plans in order to minimize the consequences of society reopening.
Abbreviations SARS-CoV-2=Severe Acute Respiratory Syndrome-related Novel Coronavirus 2, WHO=World Health Organization, UK=United Kingdom, GDP=Gross Domestic Product, CDC=Centers for Disease Control, PPE=Personal Protective Equipment