There’s a long war ahead and our Covid-19 response must adapt

For most people, there is simply no frame of reference for this pandemic. Never in our lifetime has there been a threat of infectious disease that is devastating to society. Never in our lifetime have we seen a rich country like that Italy meet the need to ration respirators. And we have never seen the fear that millions of health professionals around the world feel infected by the virus – justified fears we must address.

We learn more about this virus during the day, often per hour, and most of the news is bad. Here are five things we've learned over the past week:

  • It is not only older people with underlying conditions who become very ill and can die. Younger adults, previously healthy people and some children develop viral pneumonia. Although previous reports suggested that 80% of people had only mild disease, about half of these people, despite not requiring hospitalization, appear to have moderately severe pneumonia, which can take several weeks or longer to recover after.
  • Explosive scattering will almost certainly overwhelm the capacity of the health care system in New York City and elsewhere, leading to the inability to save patients who might otherwise have been rescued. Today's serious cases are in people infected 10 to 14 days ago who fell ill five to six days ago and have constantly come to serious illness. This means that cases will continue to skyrocket for weeks after the spread stops. Not only will there not be enough ventilators, there will not be enough supplies for the ventilators, hospital beds to support patients – or healthcare professionals to help patients.
  • Healthcare professionals are at risk. Thousands have been infected in China, more than 3,000 have been infected in Italy, protective equipment is in short supply in the United States, and as health care becomes overwhelmed, care becomes more difficult to provide care.
  • It's going to get a lot worse. Not only is the world economy free, but supply chains for necessities, including medicines, are disrupted. Even China, which has successfully reduced its spread, is only now opening the economy – producing components of many medicines people trust – and very slowly.
This is a war. And in war, strategy is important. The leading concept, now remarkably widely understood, is flat curve. This is an important tactic to protect patients and healthcare professionals from a surge that can overwhelm our hospitals, increase death rates and endanger the lives of health workers. But that is not a strategy. A month ago today, my organization, which focuses on preventing epidemics, published a concept of operations that show shading of barrier to mitigation, and the need to pause contact tracking when it became impractical and upscale social distance intervention (see link for details.)
Today we learn from another month of experience from around the world China and South Korea, we recognize a third phase of the response: suppression of episodic outbreaks. In this new third phase, comprehensive testing and alert clinical systems can immediately identify cases and clusters, intervene extensively and suppress dissemination before widespread social damage occurs.

The revised approach also recognizes that this is going to be a long war, and that we must address the extensive risk of community continuity, including health care for people with ongoing medical needs such as hypertension and diabetes, and the vulnerability of the supply chain for medicines and supplies.

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China has outlined an analogous approach, based in part on their experience with cases imported from other parts of the world. In China, Hubei Province faced a peak that overwhelmed the health care system, but other provinces managed to avoid this through aggressive containment (the purple curve below). China remains largely trapped, with only gradual reopening, expanding rapid capacity in the health care system, preparing for possible clusters or major outbreaks in the future.

There are five priorities that are important for the successful implementation of the third phase of this strategy.

Comprehensive testing and contact tracking. China has tested millions of people and tracked more than 685,000 contacts. Contact tracking requires skilled public health and sophisticated data management professionals. Testing is needed in several arenas:

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  • Healthcare. Every patient with a fever or cough and every patient who needs mechanical ventilation or with signs or symptoms of pneumonia.
  • Contact tracking. An army of skilled public health workers, potentially bolstered by new data streams such as mobile phone locations, is needed to identify vulnerable individuals, who must be isolated for 14 days after exposure. The extent to which a circle of contacts to track, and how and how often to test contacts, will depend on new information about who is spreading the infection and when during the disease.
  • Drive through. Quick, safe and practical implementation testing facilities pioneer of South Koreareduce the burden on health services, reduce the risk to healthcare professionals and others that patients may come into contact with, and identify infections among contacts and others.
  • Surveillance. We need tracking systems, including Influenza-like disease system, to find scattered and monitor trends. Syndromic monitoring systems must be set to detect possible clusters, and signals are detected immediately.

Prepare for the health care system to be able to surf safely. Every community in the country must increase the ability to safely care for a large number of patients with minimal risk to health professionals. This means not only increasing the number of beds and the availability of oxygen and ventilators, but all aspects of health care including staffing, equipment, supplies and general management.

Maintain health and routine functions in the health care system. We need to increase the resilience of both our people and our health services as quickly as possible.

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  • Increase personal resilience to health. Underlying conditions greatly increase the risk of serious illness. This is not only bad for patients who are infected, it will take up scarce health care. There has never been a better time stop smoking, get yours blood pressure under control, make sure if you have it diabetes It is well controlled, and – yes – be regular physical activity. (Being active for at least 15 minutes a day also helps Vitamin d levels. Of all the proposed measures to increase your resistance to infection, regular physical activity and adequate vitamin D levels probably has the most scientific evidence to support them – and can be done safely.)
  • Scale up telemedicine. We must reduce the number of people attending health care while maintaining and improving health. The administration issued flexible and constructive guidelines for Medicaid, but much more is needed. Patients – especially those who are not insured or who do not have a regular source of care – must be able to fill out prescriptions, get medical help and find a doctor quickly.
  • Fix weaknesses in the supply chain. This is crucial for masks and other personal protective equipment, fans and equipment for fans and laboratory materials. This is a good time to look at a core list of medicines and ensure that the safest and most effective are available. For example, in another area where my group works globally, we have found that instead of 30 or 50 high blood pressure medications, Three would be done for almost all patients. Let's make sure we have life-saving medicines and worry less about which companies make them.

Learn intensely. If this is an important lesson from previous epidemics, it is important to get real-time data for a good epidemic response.

  • The most urgent thing to do is to learn how to do it best protect health care professionals from infection.
  • We need to know which is most susceptible to the spread of the infection, and at what point in their illness – so we can target contact tracking most effectively. This will help you decide how wide a circle of contacts to track and how and how often to test.
  • Who has the highest risk of serious illness and death.
  • What works to reduce infection? What public health advice is being followed and what is the impact? Some countries require all patients, including those with mild illness, to be isolated in facilities. (This can be done, for example, in dormitories). Is this necessary and effective? Should it be extended to close contacts to prevent them from spreading the infection? The answer to these questions will partly depend on answers to other questions, such as how often people who never have symptoms, or people just starting to get sick, spread infections.
  • Is it quick care tests and how accurate and timely are blood tests for coronavirus infection?
  • Is immunity protective? Although antibodies are produced reliably, this does not necessarily mean that recovered patients are immune to a future infection.
Former CDC Director: Covid-19 is different from the flu, and we have to respond differently

For these issues, the United States Centers for Disease Control and Prevention and state and local health departments, as well as public health agencies around the world, are crucial. They are the intelligence officers needed to guide our strategy and tactics, and they must be both at the table when decisions are made and on the pallet when the policy is explained.

And these are just the epidemiological questions. We also have an urgent need to know if treatments are working. The Preliminary report the value of chloroquine and azithromycin must be carefully addressed. The disappointing findings that two antiviral medications did not improve the survival of seriously ill patients is a sobering reminder that until rigorous studies are available, we will not know how to best treat patients. Although we cannot dramatically improve the results, a treatment that reduces the need for intubation can save many lives.

A safe and effective vaccine is of paramount importance. The world must do everything possible to develop a vaccine, while recognizing that this may or may not be possible.

Adapt to a new normal. The Covid-19 pandemic will change our world forever. Until it is controlled, we must all change how we wash our hands, cover our coughs, greet others and how close we are to others. We will reassess the need for meetings and conferences. We need broadband for everyone as a public utility like mail or water. We must support the vulnerable, even if only because their illness can jeopardize our health.

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Our strategy to curb the effect of Covid-19 will necessarily evolve as we learn more about the virus and the effectiveness of various interventions.

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In a fourth phase, a vaccine, if one can be found, or global elimination efforts, if they can succeed, either end the pandemic or, if not, force us to adapt to the enduring threat of an indefinite future. We face weeks and months of fear and tragedy. Leaders at all levels need to be honest that this is daunting, unique and irrevocably changing how we care and prepare for the future. But it is also a time to recognize that we are all in this together – not just everyone in the United States, but all of us globally. Spreading anywhere in the world increases the risk everywhere. We have a common enemy, and together with a common strategy we can build a new normal that minimizes risk, maximizes collaboration and commits to shared progress.

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