The rapidity with which COVID-19 spread across the world left governments with little time to respond. Now, however, as some countries see a flattening or even a decline in deaths, many are considering what a sustainable exit strategy might look like. Ultimately, this will require a safe and effective vaccine, coupled with new treatment for those who remain unprotected. For now, however, the emphasis has been on driving the transmission number, or R0, below 1, so that each infected person spreads the disease to fewer than one other on average, and keeping it there with continuing restrictions on large gatherings, social distancing in everyday life and, increasingly, use of face coverings. However, it is also important that any exit strategy considers the broader health, economic and public policy implications of COVID-19. From a health perspective, there are shortto medium-term implications. At least some of the excess deaths during the pandemic have been due to a failure to seek necessary urgent care. A large increase in weekly deaths out of hospital where COVID-19 is not listed on the death certificate is likely, in part, to be due to underdiagnosis but has occurred at the same time as substantial declines in those attending hospital with acute coronary syndrome and strokes. Attendances in primary care have also declined and widespread cancellations of elective surgery have delayed surgeries for patients with cancer, while those with coronary occlusions have also seen procedures postponed. Treatment algorithms have been adjusted to deliver sub-optimal treatments such as shorter durations of chemotherapy, or thrombolysis instead of percutaneous coronary intervention. As a consequence, there will be a large reservoir of unmet need, some of which will have caused conditions to deteriorate, necessitating additional or more complex treatment. Exit strategies must capitalise upon periods of relative suppression of COVID-19 to ensure that those affected are identified and receive care, with prioritisation given to those with highest clinical need. Mental health, so often hidden, is a particular concern as social isolation has increased loneliness, depression and anxiety. People with substance misuse problems have suffered, as access to addiction support services has been restricted. Health workers are being exposed to traumatic experiences on a daily basis, which require early support and after care to protect against long-term mental health consequences. Finally, action will be needed to support those who have experienced domestic violence who have struggled to access safe havens. From an economic perspective, there will be a need to ensure a rapid but sustainable recovery. The International Monetary Fund estimates a 6.1% decline in gross domestic product in advanced economies in 2020, although other analyses suggest the decline could be greater. Estimates from Germany suggest that a one-month lockdown would cost between 4.3% and 7.5% of gross domestic product (E150–260 billion), and a three-month lockdown would cost between 10% and 20.6% of gross domestic product (E354–729 billion). Some politicians are arguing that the scale of the economic harm justifies lifting restrictions earlier but this view does not withstand serious scrutiny. Few people will be willing to engage in normal activities such as eating out or attending entertainment venues if the death toll is accelerating upwards and healthcare systems, which they may need for non-COVID-19 conditions, are being overwhelmed. It will be important to ensure that companies, and especially the small and medium ones that are the engine of many local economies, are able to respond rapidly to the progressive lifting of restrictions. This means that governments must take Journal of the Royal Society of Medicine; 2020, Vol. 113(5) 176–178

中文翻译：

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制定针对 COVID-19 的可持续退出战略：对健康、经济和公共政策的影响

COVID-19 在世界范围内传播的速度之快让各国政府几乎没有时间做出回应。然而现在，随着一些国家的死亡人数趋于平缓甚至下降，许多国家正在考虑可持续的退出战略可能是什么样子。最终，这将需要一种安全有效的疫苗，并为那些仍未受到保护的人提供新的治疗方法。然而，目前的重点是将传播数或 R0 控制在 1 以下，以便平均每个感染者将疾病传播给的人数少于其他人，并通过继续限制大型集会、保持社交距离来保持这一水平在日常生活中，并且越来越多地使用面罩。然而，同样重要的是，任何退出策略都要考虑 COVID-19 对健康、经济和公共政策的更广泛影响。从健康角度来说，有短期和中期的影响。大流行期间至少有一些额外的死亡是由于未能寻求必要的紧急护理。在死亡证明上未列出 COVID-19 的情况下，每周出院死亡人数大幅增加可能部分是由于诊断不足，但与此同时，因急性冠状动脉综合征和笔画。初级保健的出勤率也有所下降，选择性手术的广泛取消导致癌症患者的手术延迟，而冠状动脉闭塞患者的手术也被推迟。治疗算法已被调整以提供次优治疗，例如更短的化疗持续时间，或溶栓而不是经皮冠状动脉介入治疗。作为结果，将会有大量未满足的需求，其中一些会导致条件恶化，需要额外或更复杂的处理。退出策略必须利用 COVID-19 的相对抑制期，以确保受影响的人得到识别和接受护理，并优先考虑临床需求最高的人。由于社会孤立增加了孤独感、抑郁和焦虑，因此往往隐藏起来的心理健康尤其令人担忧。由于成瘾支持服务受到限制，有药物滥用问题的人受到了影响。卫生工作者每天都面临创伤经历，这需要早期支持和后期护理，以防止长期的心理健康后果。最后，需要采取行动支持那些经历过家庭暴力但难以获得安全庇护所的人。从经济角度来看，需要确保快速但可持续的复苏。国际货币基金组织估计 2020 年发达经济体的国内生产总值将下降 6.1%，尽管其他分析表明降幅可能更大。德国的估计表明，为期一个月的封锁将花费国内生产总值的 4.3% 至 7.5%（E150-2600 亿欧元），三个月的封锁将花费国内生产总值的 10% 至 20.6%（E354- 7290 亿）。一些政客争辩说，经济损害的规模证明提早取消限制是合理的，但这种观点经不起严格审查。如果死亡人数加速上升，并且他们在非 COVID-19 情况下可能需要的医疗保健系统不堪重负，很少有人愿意参加正常活动，例如外出就餐或参加娱乐场所。重要的是要确保公司，尤其是作为许多地方经济引擎的中小型公司，能够对逐步取消的限制做出快速反应。这意味着政府必须拿英国皇家医学会杂志；2020，卷。113(5) 176–178 尤其是作为许多地方经济引擎的中小型企业，能够对限制的逐步解除做出快速反应。这意味着政府必须拿英国皇家医学会杂志；2020，卷。113(5) 176–178 尤其是作为许多地方经济引擎的中小型企业，能够对限制的逐步解除做出快速反应。这意味着政府必须拿英国皇家医学会杂志；2020，卷。113(5) 176–178