COVID-19 Poses Challenges in a Global World
Editor's Note: Information on COVID-19 continues to evolve on a daily ... and sometimes hourly ... basis. Much of the information contained in this article is of a general nature, and numbers have been updated for the online piece as of March 10th. However, the situation continues to be fluid. When this piece was originally written, there were no confirmed cases of coronavirus. As of March 10, there are now seven with four in Williamson County, one in Davidson County, one in Shelby County and one in Sullivan County.
As the March issue of Medical News went to press, there were more than 83,000 confirmed cases of the latest coronavirus across more than 50 countries with nearly 3,000 reported deaths. The virus is now on every continent except Antarctica. By March 10, the number had risen to 118,000 reported cases and nearly 4,300 deaths ... and the entire country of Italy was on lockdown.
In the United States, the Centers for Disease Control and Prevention reported 647 confirmed and presumptive positive cases and 25 deaths across 35 states plus the District of Columbia on the afternoon of March 10. By lunchtime on March 11, cases had jumped to more than 1,000 across 38 states and D.C. with a death total of 31. Washington state has, by far, had the highest death toll with 25 reported deaths primarily among elderly residents in long-term care settings.
World Health Organization Director-General Tedros Adhanom Ghebreyesus, PhD, MSc, has steadfastly called for facts over fear. He outlined both signs of hope and causes for growing concern in one of the regular addresses he has held since it became clear COVID-19 poses a global threat.
In a late February address, Tedros said the WHO-China Joint Mission team had returned after traveling to Wuhan, China, the epicenter of COVID-19. "They found that the epidemic peaked and plateaued between the 23rd of January and the 2nd of February and has been declining steadily since then," he noted. Additionally, the team found no significant change in the DNA of the virus, which is good news.
As for the arc of the virus in those who contract it, Tedros said people with mild disease recover in about two weeks, while those with severe or critical disease take three to six weeks to recover. The team, he continued, "found that the fatality rate is between 2 percent and 4 percent in Wuhan and 0.7 percent outside Wuhan."
However, since that statement, many public health officials have recognized the denominator being used to figure the death rate is almost certainly under counted. Testing criteria is changing, which is anticipated to reveal more mild cases. Even if the rate comes down, it appears to be significantly higher than rates seen with the flu, and the virus has proven to be particularly deadly for the elderly and those with underlying health conditions.
Epidemic or Pandemic
Tedros noted many countries have been aggressive in trying to contain the virus so far. However, he said the sudden increases seen in Italy, Iran and South Korea in late February were "deeply troubling."
He continued, "There is a lot of speculation about whether this increase means that this epidemic has now become a pandemic." By the end of February, WHO had raised its coronavirus risk assessment to "very high" but still wasn't calling the outbreak a pandemic.
"Our decision about whether to use the word 'pandemic' to describe an epidemic is based on an ongoing assessment of the geographical spread of the virus, the severity of disease it causes, and the impact it has on the whole society," he explained. "For the moment, we are not witnessing the uncontained global spread of this virus, and we are not witnessing large-scale severe disease or deaths. Does this virus have pandemic potential? Absolutely, it has. Are we there, yet? From our assessment, not yet."
Instead, he said there are epidemics in different parts of the world affecting countries in different ways that require a tailored response. Although there isn't a one-size-fits-all approach to a country's risk assessment for COVID-19, Tedros said there should be at least three priorities for everyone.
"First, all countries must prioritize protecting health workers. Second, we must engage communities to protect people who are most at risk of severe disease ... particularly the elderly and people with underlying health conditions. And third, we must protect countries that are the most vulnerable by doing our utmost to contain epidemics in countries with the capacity to do it."
He also said it's critical for all countries, communities, families and individuals to focus on preparedness should the spread worsen. "We do not live in a binary, black and white world ... it's not either/or," said Tedros. "We must focus on containment while doing everything we can to prepare for a potential pandemic."
Since that late February statement, the number of cases, deaths and countries involved have increased. On March 11, WHO declared COVID-19 a pandemic. Tedros noted the number of cases outside of China has increased 13-fold over the past couple of weeks, while the number of affected countries has tripled.
"WHO has been assessing this outbreak around the clock, and we are deeply concerned both by the alarming levels of spread and severity and by the alarming levels of inaction," he said. "We have, therefore, made the assessment that COVID-19 can be characterized as a pandemic."
He added the word 'pandemic' is not one to be used lightly or carelessly and should not cause unreasonable fear or unjustified acceptance that the fight is over. Tedros said the WHO's course of action would continue and noted the organization has rung the alarm bell loudly from the beginning, calling upon countries to take urgent and aggressive action. He added that just looking at the broad numbers doesn't tell the full story since more than 90 percent of global cases reported are in just four countries, and two of those - China and South Korea - have significantly declining epidemics.
"We cannot say this loudly enough, or clearly enough, or often enough - all countries can still change the course of this pandemic." For countries that have few or no cases, he said definitive actions to test, treat and isolate could prevent spread. "Even those countries with community transmission or larger clusters can turn the tide on this virus."
Coronavirus & COVID-19
William Schaffner, MD
Renowned infectious disease specialist William Schaffner, MD, professor of Medicine in the Division of Infectious Diseases at Vanderbilt University School of Medicine, noted coronaviruses are respiratory in nature. Severe acute respiratory syndrome coronavirus (SARS-CoV) and Middle East respiratory syndrome coronavirus (MERS-CoV) are two examples of outbreaks in the recent past.
"Human coronavirus is not typically serious. It just causes common colds," said Schaffner, who also serves as medical director for the National Foundation for Infectious Diseases. "However, some circulate in other animals and occasionally, they - quote/unquote - jump species."
In the 2002-2003 SARS epidemic, he said the virus probably came from small bats and civets. Schaffner added the 2013 MERS virus was more directly linked to camels. "The current coronavirus has some bat genome, but it likely came to us through another animal that is yet to be identified," he said.
He added the death rate of COVID-19 at this point appears to be less than SARS or MERS but more than influenza. Schaffner said even a low death rate, however, could have a huge global impact. "Even if the rate of death is small, since it affects so many people, the absolute number of deaths becomes large," he pointed out.
"In China, they are in the midst of conducting the largest human public health experiment of all time," said Schaffner of the massive quarantine that included not only Wuhan but the entire Hubei province. More than 15 million people have been essentially locked down, although discussions about easing some quarantine restrictions were beginning to occur at press time.
"Wuhan is a teeming metropolis of 11 million people. Now it's a ghost town," said Schaffner. "The population obeyed (the quarantine), and that's the whole point."
Interestingly, he added, "Much of the world did something else - they quarantined China." International airlines cancelled flights and most interaction with China hit pause. As the virus began spreading to other countries, similar containment efforts were undertaken - from keeping passengers on cruise ships to quarantining evacuated nationals back in their home countries. Following a sharp spike in cases in late February, Italy quarantined a wide swath of the northern region and enforced a ban on public events in 12 municipalities.
"If people can't congregate, the virus can't spread," said Schaffner, adding that if COVID-19 does continue spreading despite quarantines, that would be greatly concerning. "Now is about the time we would expect to see cases drop if this is working," he continued.
The effectiveness of quarantines also has to be factored into any review of the containment process. "The cruise ships clearly provided a challenge to public health," said Schaffner. "That turned out to be much less successful than anybody anticipated."
Editor's Note: Since the original article was prepared, 'social distancing' has become part of the vernacular. New York has instituted a containment zone around a hotspot in New Rochelle where there are more than 100 cases. Numerous medical conferences and large public events have been cancelled or postponed.
Another issue hampering analysis of the outbreak has been fluid definitions of confirmed cases coming out of China. "The case counts and what they mean have been very difficult to interpret," said Schaffner. "How you identify cases was defined and redefined and redefined again."
While glad WHO has been on the ground in China, Schaffner said he would have liked to have the CDC there, as well. Having the CDC on site, he added, would have helped iron out definitions for COVID-19, but China did not extend permission to the U.S. experts. Had they done so, Schaffner said, "We would have been receiving a more rigorous and sustained flow of information."
Editor's Note: New cases reported in China have seemingly slowed significantly over the past couple of weeks. Meanwhile, cases in other countries are increasing rapidly.
Public Health & Patient Safety
While it's impossible to be perfectly prepared or to predict exactly how much damage COVID-19 will cause going forward, Schaffner pointed out the United States has a robust public health system.
In diagnosed cases, patients are being immediately isolated, Schaffner continued. "In close cooperation, our public health officials - local, state and federal - have worked hand-in-glove with clinicians to identify all the contacts of those infected and notify them," he said of the U.S. containment protocol.
That said, the spread of COVID-19 in other countries has led the CDC to predict additional cases in the United States will be "inevitable." Going forward, providers who encounter patients with a fever and respiratory complaints should ascertain whether they have recently traveled to an affected area or been in contact with someone who has. If the answer is yes, Schaffner said to immediately put a mask on the patient, isolate them and call the state health department. "They will help you manage the patient from then on," he noted.
One issue that has frustrated public health officials has been the ongoing problems surrounding the rollout of testing kits. CDC officials said they have modified the testing protocol and worked out technical difficulties, which should improve timely diagnostics.
Editor's Note: At press time the CDC had confirmed the first case of coronavirus of 'unknown origin' in the United States in a patient who had neither traveled to an affected region nor been in contact with another known patient. The new case raised the specter of "community spread." As a result, the CDC has broadened its criteria for testing.
When it comes to treating large-scale public health concerns, it requires an 'all hands on deck' approach utilizing clinicians, technology, researchers and all available community resources. Global epidemics put major stress on broader medical and financial systems. Even if COVID-19 only caused mild illness, Schaffner said, "It would have profound economic and social implications."
In an increasingly global marketplace, that toll has been evident. Entire towns and regions are being told to stay home, bringing commerce to a halt. Plants are closed in China so parts can't ship, which in turn halts production of goods across the globe. In a three-day span in late February, the Dow Jones lost more than 3,000 points in response to the coronavirus, and it dropped more than 2000 points in a single day in early March.
The medical system is also strained in the face of pandemic. Pointing to the 2009 influenza strain, Schaffner said, "It stressed the medical care system in the United States. It will do that wherever you go." He noted no country can be "perfectly prepared" for such events. Hospitals don't sit empty waiting for an outbreak. No one stocks enough ventilators or masks to care for the majority of the population. "Any society is going to be severely stressed if you have a genuine new pandemic," Schaffner added.
Those natural stresses are exacerbated by shrinking dollars. "We have a robust public health setup in the U.S., but public health departments at a state, local and federal level have had their budgets trimmed and whittled over the last 20 years," he said. While the president's current budget calls for significant cuts for the CDC, the administration did request $2.5 billion specifically for the coronavirus fight and received $8 billion instead.
Schaffner pointed out being prepared to battle novel coronaviruses or other emerging threats requires sufficient, sustainable funding to lay the groundwork long before the flames are licking at the door. "If you're going to fight fires, you better have highly trained firefighters in place," he concluded.
Putting Technology to Work for Public Health
Lisa Ide, MD, MPH, chief medical officer for Minneapolis-based Zipnosis, a national virtual care platform, said technology has an important role to play in tracking and messaging during public health outbreaks. Ide noted, "One of the most powerful tools virtual care can offer us is the ability to automate triage." She continued, "In an outbreak, a key effort is to determine who needs screening." Ide added the Zipnosis platform guides patients to the most appropriate level of care based on symptoms.
The technology also allows telehealth companies to quickly modify protocols and add pertinent questions that can be deployed locally for community-specific outbreaks or across all systems for national epidemics. "We were able to add a travel question very quickly in our upper respiratory infection protocol," she said of screening for COVID-19. "We can add required questions to our adaptive interviews which deploy in our health systems across the U.S." In the current case, Ide said the open-ended question asks patients to list places traveled in the last 14 days. As the coronavirus spreads beyond China, it allows providers to flag stays in other hotspot areas, as well.
"The third way a virtual technology platform is helpful is we have real-time data on symptoms and diagnoses," she noted. "This can be used to track patterns and the potential spread of communicable disease."
Ide said virtual care platforms also play an important role in education and the distribution of information. "We are able to embed key public health messages in our visits - both for patients and for providers."
During a measles outbreak several years ago, Zipnosis distributed evidence-based information to all patients accessing the system. Equally important, they were also able to remind providers in the affected area to be on the lookout for routine complaints that could actually be the early symptoms of measles, including fever, runny nose and dry cough.
Yet another advantage of technology in any contagious occurrence - whether it be flu, measles or coronavirus - is to limit contact with others. If a reportable condition is suspected, online providers have the opportunity to direct patients to wear a mask or go to a specific area for a face-to-face appointment that is separated from the general patient population.
For those with mild disease that doesn't require patients to be seen in person, Ide added, "We can keep a lot of infectious, but not necessarily seriously ill, patients at home. We can treat them virtually and keep them out of waiting rooms."