Coronavirus Care Planning 'More Important Than Containment'

Ingrid Hein

February 14, 2020

Although quarantines and the number of people affected are dominating the headlines about the coronavirus, emergency preparedness — not COVID-19 containment — is the more appropriate response, said Amesh Adalja, MD, an infectious disease specialist at the Johns Hopkins Center for Health Security in Baltimore.

"We're seeing an over-reaction in the form of quarantines," he told Medscape Medical News. "But that's not the full picture of the virus."

The very aggressive early actions taken in China set the tone for the world, Adalja explained. "It will take time to right-size the response. We need to move away from focusing on containment and understand how it affects humans."

Adalja will try to unravel the mystique around the novel coronavirus, with up-to-the minute information on the bug, during a panel discussion on worldwide threats to health security at the Society of Critical Care Medicine (SCCM) 2020 Critical Care Congress in Orlando.

Overall, our health systems might be more prepared than in the past, but making the right decisions is still a challenge, he explained.

More than 80% of people affected have a mild form of COVID-19. "This is not SARS," he pointed out. Although the respiratory transmission of COVID-19 makes its spread very efficient, the illness caused is milder than was seen during the SARS outbreak.

Given the current information, Adalja said he believes the severity of COVID-19 lies somewhere between a community-acquired coronavirus, such as OC43, HKU1, or NL63, and SARS. It's likely to evolve much like H1N1, from a novel pandemic coronavirus strain to an endemic seasonal strain that causes about a quarter of cases of the common cold, he said.

Still, there will be an impact on ICUs.

Impact on ICUs

"Like any respiratory illness, people of advanced age and those with other medical conditions get hit the hardest. That's where it's clustering, so hospitals need to be ready for a surge of patients," he warned.

Because this is the first year of the virus, it will likely hit hard this year, "but it will be a mild pandemic," he predicted. "We now know it's not like SARS; it's not as fatal. That's a relief."

A pandemic of flu caused by airborne viruses is inevitable, according to a 2019 report on health emergencies from the Global Preparedness Monitoring Board, the World Health Organization, and the World Bank. And current preparedness is "grossly insufficient."

A fast-moving pathogen can kill tens of millions of people, disrupt economies, and threaten national security, the report warns.

COVID-19 is unlikely to cause the mass disturbance described in this report, but experts are still pushing for better preparation.

Hospitals in the U.S. have done some preparation. Providers for the Centers for Medicare and Medicaid Services have been required to have some level of emergency planning in place since a final rule was published in 2016.

But the robustness of those plans differs. "Emergency committees vary; some just tick the checkboxes required and others are more emboldened and look for threats," Adalja explained.

When an epidemic emerges, it's important to have contingency plans in place. "You don't want to be responding on the fly," he said.

The key is to understand the epidemiology of a new infection. "In the early days, you get data that are very skewed; you hear about the severity first, about ICUs and deaths," he noted. Fast action is required, but with epidemiologic understanding.

This is a view echoed by others, including psychiatrist Dinah Miller, MD, who recently wrote about public anxiety being out of proportion to the threat posed by COVID-19 in a Medscape commentary.

Still, COVID-19 will be disruptive to hospital operations, Adalja pointed out. "It will be something hospitals will have to cope with, and most are running at full capacity now. ICUs are critical for the part of the population that will get severe disease, and they have to be prepared. Do they have enough beds? Airborne isolation rooms? Ventilators? There may be a demand for extracorporeal membrane oxygenation. All this can be a challenge," he said.

Although ICUs are far more prepared for a pandemic than ever before, "we need to practice good judgment," said Adalja. "It's about knowing when to apply emergency measures."

Travel bans and quarantines add to the panic, he pointed out, and "are not reflective of the mostly mild individual risk."

Restriction on movement is "one of those kinds of things that are going to be controversial from a medical point of view," said Anand Kumar, MD, from the University of Manitoba in Winnipeg, Canada, who will discuss preparedness at the upcoming SCCM meeting.

But at this time, it makes no sense whatsoever to issue travel bans, he said.

"We need to stay focused on the rising seas and not get too distracted by tsunamis," Kumar said. "Sure, the tsunamis are more newsworthy," he acknowledged, but "antimicrobial resistance is the rising sea in the area of infectious disease. It's quickly becoming a huge problem."

Blood tests that rapidly identify pathogens and can measure drug resistance are in development. Short-course antimicrobial therapy, which has proven to be effective for intra-abdominal infection, needs to be further researched. Antimicrobial stewardship is increasingly important in the fight against antimicrobial resistance. "Genetic testing techniques are also improving," Kumar reported, providing clinicians with more narrow-spectrum therapies to offer.

But most desperate is the need for novel antimicrobials. "They haven't been a high priority for drug companies because they're not profitable," Kumar said.

"We need get far enough inland to stay dry from both antimicrobial resistance and tsunamis, because either one can flood you," he added.

Society of Critical Care Medicine (SCCM) 2020 Critical Care Congress: Session 1351. To be presented February 16, 2020.

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