What scares you?

I’m on a quick weekend trip for a wedding—a trip made possible only because we have a high concentration of hospital epidemiologists in Iowa City, and we haven’t yet diagnosed* a case of COVID-19 (*like much of the country, we’re behind in testing).

It’s disorienting to go from non-stop response planning questions to connecting with old friends. But of course the questions still came, the most common being: “are you scared by this?” My response was “yes”. Here are the three reasons I gave for my concern (before trying to turn the conversation to other things!), in no particular order:

Our healthcare system lacks surge capacity, and is already overstretched. Large tertiary care centers commonly run at capacity with overflowing emergency departments and patients “orbiting” (awaiting transfer from smaller hospitals for a higher level of care). The proportion of COVID-19 patients requiring admission and ICU-level care will quickly overwhelm US hospitals if spread continues at plausible estimated rates. This will cripple our ability to care not only for COVID-19 patients for all others requiring hospital care.

Residents of long term care facilities (LTCF, including long term acute care, rehabilitation centers, etc.) are extraordinarily vulnerable. We know from experience that once a transmissible pathogen enters a LTCF it spreads quickly, and the experience at the Life Care Center in Washington is terrifying.

The social and economic disruption caused by COVID-19 may kill more than the virus does directly—particularly in countries that have frayed or nonexistent social safety nets (I include the US in the “frayed” category). Job loss, loss of health coverage, homelessness, all carry with them additional morbidity and mortality that will continue long after the COVID-19 pandemic is over.

What do my fears imply for response planning?

Lack of surge capacity requires aggressive approaches to keep all but the sickest patients out of the hospital (telehealth, home health), and developing plans for conversion of some general hospital units to ICU-level care if needed. No surge capacity also strengthens the argument for aggressive social distancing approaches in an attempt to “flatten the curve” of the epidemic (amazingly helpful graphic below, and great Twitter thread here), while admittedly worsening the social/economic disruption problems.

The vulnerability of LTCF residents requires drastic measures to protect these facilities—limiting facility access, screening employees for URI/ILI daily, and reducing social contact in ways that could still allow interaction (computer/tablet visits, etc.). Some may even wish to investigate temporary relocation of some residents (e.g. to family with visiting nurse assistance). LTCFs look more and more like the highest risk environments for COVID-19 (combining transmissibility with case fatality rate).

The social and economic disruptions are the most difficult to address. In the near term, it requires recognizing when some of the more disruptive control strategies are no longer providing a benefit that overrides the ongoing damage to society. As one example, I think we’re reaching a point at which travel restrictions will have diminishing returns. This excellent modeling paper demonstrates the likely benefit of travel bans from China before extensive international spread had occurred. The impact of travel restrictions is likely to be much less now that the virus is so widespread globally. In fact, I think the motivation for many current travel restrictions being implemented in the US is out of fear that the traveler will be subject to home quarantine upon return (and unable to work or contribute to response efforts)—once community spread is documented across the US, the use of home quarantine after travel becomes illogical. Moreover, the whole idea of quarantining healthcare personnel after exposures needs to be abandoned if we hope to have any work force for patient care. CDC recognizes this in recent updated guidance.

OK, now that I’ve revived this recently moribund blog, we’ll have to address some more COVID-19 controversies soon. Or you could just search the site for our 10 year old posts about the H1N1 N95 mask fiasco?