Three physicians from Johns Hopkins University, Baltimore, MD, joined efforts to write an article detailing important action points to be made by the U.S. healthcare system in response to COVID-19.
The paper was written by Dr. Amesh A. Adalja, Eric Toner and Thomas V. Inglesby titled “Priorities for the U.S.
The doctors are all from the Johns Hopkins Center for Health Security and the Department of Environmental Health and Engineering at the university.
The article, which appeared in the JAMA newspaper, draws on experiences with previous epidemics — such as the 2009 influenza pandemic, the 2003 SARS epidemic, and the 2005 avian influenza A outbreak — to describe crucial steps that the U.S. government and healthcare sector should take to address the new coronavirus.
Hospitals, clinics, and other facilities
First, the authors write that healthcare organizations will update preparedness plans built for the previous epidemics.
“These recommendations discussed, generally speaking, the protection of healthcare workers, how to deal with staff shortages, patient rises, triage problems, and finite resource management,” Dr Adalja and colleagues write.
Second, hospitals and clinics which have “critical roles” in responding to COVID-19 must develop specific “protocols for the trial and isolation of patients suspected of infection in emergency departments and emergency care centres.”
Importantly, the authors write, “Similar procedures need to be implemented in ambulatory clinics, dialysis centers, and other medical facilities— especially nursing homes, assisted living centers, and long-term care facilities with particularly vulnerable populations.”
This is to prevent COVID-19 from affecting regular treatment in medical care units, which would “compound direct morbidity.”
Healthcare workers and ICU units
Additional key concern in the COVID-19 response is the safety of health care workers. This will include the use of personal protective equipment, revised hospital administration procedures and hospital personnel special training, the authors note.
A large number of patients are likely to be seriously ill, so hospitals need to pay particular attention to the planning of their intensive care units (ICUs), Dr. Adalja and colleagues write, explaining:
“This planning includes evaluation of ICU bed capacity, the ability to augment ICU-level bed space with alternative care sites such as step-down units and postanesthesia care units, mechanical ventilator stock and supply chains, and the logistics of isolating and cohorting patients.”
“Most hospitals are already running at or near capacity, and even an above-average flu season can cause operational disruption,” the authors point out.
Finally, the team emphasizes that— while too little is currently known about COVID-19 and healthcare professionals will have to change their clinical practices as more information becomes available— adhering to existing recommendations for pneumonia, sepsis, and acute respiratory distress syndrome (ARDS) is the best course of action.
“This may include the use of investigational antiviral or monoclonal antibody therapy,” the authors note.
More diagnostic tests needed ‘rapidly’
Clinicians must also “rapidly” extend their diagnostic testing, they write.
“For a clearer understanding of the burden of COVID-19, medical and public health professionals need to expand research to all patients with unexplained ARDS or serious pneumonia, and eventually to patients with mild symptoms associated with COVID-19.”
The researchers explain that the Centers for Disease Control and Prevention (CDC) — which initially performed all diagnostic tests — and public health labs do not have the capacity to perform testing on the scale that is necessary right now.
“The production and manufacture of test kits on a large scale would allow the major clinical diagnostic companies to achieve a high-level testing capability. Diagnostic firms may simply add SARS-CoV-2 to existing respiratory viral panels based on nucleic acid, or build stand-alone tests. Ideally these diagnostic tests would be simple,” cautions the paper.
Serological assays, blood tests for different antibodies are also needed to help assess an accurate case fatality rate and the authors point out that for monitoring purposes.
Public health and social distancing
“SARS-CoV-2 has been a quasi-impossible containment problem from the outset,” the team writes.
This is because the virus transmits very effectively; the authors note that the virus has “surreptitiously spread for at least 6 weeks” and has “an outbreak doubling time of approximately 1 year.”
“As more and more countries report cases, including those with no link to the disease epicenter, it is clear that there are many more unrecognized cases in the world and that community transmission is happening in many countries.”
– Dr. Amesh A. Adalja et al.
The most important behaviors which can delay the spread of SARS-CoV-2 are public health measures such as providing fast diagnosis and isolating people with the virus.
Monitoring people’s experiences with the virus and putting them in quarantine at that early stage of the outbreak may also be effective.
“However, it will no longer be feasible to monitor all interactions beyond a certain level.” At this stage, actions known as “social distancing” may be appropriate. These include “cancelation of large gatherings, where feasible telecommuting to work, and closing of colleges.”
These measures, however, will come at a cost for which account must be taken. For example, school closures will mean that “many children who rely on school meals will not receive them, and many single parents will be out of the workforce.”
Finally, in addition to communicating safety steps that everyone can take to minimize the spread of the infection, “It’ll also be necessary to communicate […] that people who test positive for this virus but don’t need a hospital care should stay at home while they are ill and not go to hospitals.”
“Hospitals may have serious challenges in managing the number of people who need acute care, so it will be necessary not to add to hospital demands for those who are sick but otherwise well.” Dr. Adalja and his fellow Members conclude:
“Preparation will take time, so healthcare and public health systems need to move quickly forward in their efforts to be ready to confront this disease around the country.”
For information on how to prevent the spread of coronavirus, this CDC page provides advice.