As an internal medicine resident working at Mount Sinai Hospital in Manhattan, COVID-19 has taken over our workroom conversations as the number of new cases enters exponential growth. Yet, until about a week ago, many of my colleagues still had COVID-19 pegged as just another respiratory illness to add to a long list of viral infections mild for the vast majority and deadly to the vulnerable few. To prevent its spread, wash your hands as much as possible and isolate the suspicious cases. The bottom line: keep calm and carry on.
As an anthropologist who lived in Wuhan for a year and has regularly kept in touch with physicians there since the city was placed under lockdown on January 23, 2020, COVID-19 has proved to be an unprecedented crisis. Personal and professional lives were turned upside down as Chinese doctors took up living in mandatory quarantine and worked under layers of protective gear for as long as they did not suffocate.
If first-hand accounts of colleagues and friends in Wuhan seemed surreal at the time, I simultaneously confronted a sense of disbelief at the response of the American medical community. As an anthropological observer, I worry that the American medical community’s failure to register the historical uniqueness of COVID-19 has impeded its containment.
The novel coronavirus entered my professional conversations in New York on January 24, when a noon conference on the new disease at my hospital described its symptoms as influenza-like and its case fatality rate as likely comparable when all was said and done. Such descriptions were made a day after Wuhan, a city of 11 million, was placed under lockdown even while the total number of confirmed cases was still less than a thousand. Since then, Wuhan’s public health infrastructure transformed to prioritize COVID-19 containment. Hospitals were radically reorganized as all but three major hospitals in Wuhan were converted into coronavirus units. All other kinds of medical activities became casualties to an all-out mobilization to curb the epidemic. In the official tallies since the lockdown of Wuhan, the number of COVID-19 cases rose steeply and then — as of the first week of March — plateaued.
As similar measures are being proposed and some even implemented around the United States, none of what I’m describing should come as a surprise. On February 10, I spoke with a cardiologist friend of mine in Wuhan who was by then working on a coronavirus unit like every other doctor at her hospital. She was being told then that the containment effort would have to be sustained until May. A pre-print article from March 6, 2020 modelling the spread and containment of COVID-19 in China notes that after February 2, with centralized treatment and quarantine of all COVID-19 cases in Wuhan, the epidemic entered its final stage as all effective countermeasures were rolled out. The team of researchers based in Harvard, Fudan and Huazhong Universities projects that by early May, there would be no more cases of COVID-19 in China.
February 2 is almost exactly two months from the first documented case of COVID-19 in China on December 1, 2019. By March 20, we in the United States would be about two months out from our first documented case of COVID-19, when a man in Washington state was diagnosed. We now know that through him, the coronavirus has continued to spread in the Seattle area. Instead of a concerted roll out of epidemic countermeasures, however, the United States has squandered much of these last two months.
Containing the coronavirus requires a multi-prong effort that starts with testing and ends with tracking down and treating every patient. Because of the botched rollout of the testing kit, the states that led in the number of cases were initially just testing more than other states. If testing capacity is fully enabled, hospitals must then be ready for a large influx of cases to quarantine and treat. On this front, the response at my hospital and, I suspect, many U.S. hospitals, will appear sorely inadequate.
This brings me to the pivotal role of infection prevention. For the public, this involves hand-washing and not touching your face with stern warnings to not hoard face masks. Unfortunately for health care workers, there is not much more. The news is filled with images of health care workers wearing full-body coveralls, but the current CDC guidelines do not include these iconic suits under any circumstance.
More disturbing still, the current CDC guidelines recommend taking precautions such as wearing an N95 mask only in the event of conducting aerosolizing procedures on a patient suspected or confirmed to have COVID-19 who is already placed in isolation. This is a major change that came into effect on March 10. Previously, all clinical interactions with suspected and confirmed COVID-19 patients required an N95 respirators. For routine procedures with a high risk of aerosolizing, such as taking a nasopharyngeal swab, the CDC now also parenthetically allows surgical masks to be used when N95 respirators are not available. There is no mention of elevated protection for health care workers in regular inpatient wards, emergency departments or other sites of triage where the number of unconfirmed COVID-19 cases will appear in growing numbers. As I outlined in an open letter to the Department of Infection Prevention at Mount Sinai Health System, these revisions were made under pressure from local health authorities desperate to preserve a dwindling supply of personal protective equipment (PPE) rather than with best evidence and health care workers’ safety in mind.
Epidemiologists will hasten to add that the efficacy of protective equipment arises as much from the types of equipment used as how they are used. But on this front, efforts to prepare frontline health care workers have thus far trickled. After our hospital confirmed New York City’s first case of COVID-19, I attended an in-person refresher course on donning and doffing personal protective equipment on March 5. I wasn’t too surprised to discover that me and every doctor I know has been taking off isolation gowns incorrectly, increasing the risks of contaminating ourselves. Yet, the refresher course was not compulsory and only about 50 providers attended that day.
While COVID-19’s routes of transmission are still an active area of research, it is a useful mental exercise to imagine that it spreads like influenza. Hospitals routinely impose infection control precautions around influenza, including hand hygiene, wearing surgical masks, isolating patients and immunizing health care workers. When all these measures are perfectly implemented, one model shows the rate of transmission within hospitals could be halved. In the absence of vaccines, precautions including isolating patients and wearing surgical masks and isolation gowns is likely to be less effective against COVID-19. But even 50% reduction in the transmission of COVID-19 means that it will certainly spread inside hospitals. Ergo, even if current infection prevention protocols are perfectly practiced, they would be inadequate to contain the nosocomial spread of COVID-19.
Perhaps this is why the protective equipment used in China and elsewhere around the world appear so excessive. In my analysis of the infection control guidelines of a major hospital in Wuhan, the recommended PPE involved more layers and the routine use of N95 respirators for almost all clinical settings. Every zone of the hospital, including areas of triage and the CT suite, were risk stratified for health care workers to don different types of PPE. Decontamination areas were set apart so elaborate doffing procedures could be collectively undertaken and observed. This not only preserved the available supply of PPE by strict cohorting of patients and obviating donning and doffing with each patient encounter, it also enabled health care workers to observe a higher level of precautions throughout the hospital with little ambiguity. The impression is that the infection control department at this hospital was not content to incrementally bring down the transmission rate. The thousands of health care workers infected in the beginning of the epidemic, many by asymptomatic patients, taught them better. Rather, their goal is to eliminate nosocomial transmission so they will never find out if COVID-19 is indeed capable of eliminating 3% of the general population.
It’s not too late for the health care community to switch gears and realize that routine containment measures will not fend off COVID-19. When PPE are in short supply, rather than lower the recommendations, we can make a collective effort to expand the supply chain and extend the use of existing supplies. The CDC even has recommendations for how to safely reuse N95 respirators. The CDC can require a higher level of infectious precautions across all health care settings, preempting a general dissemination in cases rather than reacting case-by-case. Routine countermeasures will not quell COVID-19. If we are to emerge from this crisis relatively unscathed, our infection control practices inside and outside of the hospitals will have to radically transform.
Image source: China Daily via Reuters