As COVID-19 Story Evolves, Doctors Stress Caution, Common Sense

Going Viral

By JOSEPH BEDNAR

How do you slow down a viral infection?

“The standard routes to prevent respiratory illness would follow the same recommendations we have in cases of influenza or the common cold,” said Dr. Robert Roose, chief medical officer at Mercy Medical Center. “This coronavirus is a respiratory virus that seems to be spread through droplets from coughs and sneezes. To prevent the spread, we strongly recommend that people take proper precautions, including washing their hands regularly with soap and water or an alcohol-based hand sanitizer, cover their coughs and sneezes, and stay home if they’re sick.”

So, it’s just like a cold, right? Or maybe the flu. Lots of people get the flu, so why should COVID-19, the specific type of coronavirus currently dominating the news, be any different?

But it is different, both because of what we do know — the mortality rate seems to be much higher than that of the flu — and what we don’t: specifically, when it will begin moving rapidly across the U.S., how many people will be infected once it does, and how many cases will be life-threatening.

“We remain on alert in Western Massachusetts for patients who have a history of travel to one of the affected areas or contact with someone who has a confirmed COVID-19 infection.”

No one knows those answers for sure, which is why hospitals are preparing for all contingencies.

“We have an emergency preparedness committee, but those policies are sort of general,” said Dr. Joanne Levin, medical director of Infection Prevention at Cooley Dickinson Hospital. “We’ve had a lot of incidents in the past decade — we’ve prepared for Ebola, measles, H1N1, a lot of things. But each epidemic is different in how it’s transmitted and what to watch for. With each epidemic, we have to go through the emergency preparation plan and figure things out.”

Roose echoed that thought “We have a standard infection-control committee and a plan that we would activate whenever we have a surge of infectious-disease patients,” he told HCN. “This particular situation is rapidly evolving. We are regularly in touch with the state Department of Health as well as monitoring guidance from the Centers for Disease Control. That’s important to ensure all of our activities are aligned with the latest data and resources.”

The day before HCN went to press last week, Gov. Charlie Baker convened a high-profile meeting with leaders of hospitals, public-health boards, emergency response, long-term care, and higher education to discuss ongoing preparations for COVID-19 in Massachusetts.

“While the risk for COVID-19 in Massachusetts remains low, our partnership with these organizations and leaders is crucial to ensuring that the Commonwealth remains safe and prepared,” Baker said.

Health and Human Services Secretary Marylou Sudders added that “the Department of Public Health has been working closely with the CDC since the beginning of the outbreak in China, and has worked tirelessly to plan and communicate with state and local partners to prepare our communities and share specific strategies all of us can take to stay healthy.”

What does all this mean? Perhaps something completely different depending on when you read this — the coronavirus scare is, after all, a rapidly evolving story and, therefore, a bit of a moving target. But the message emerging from hospitals and state agencies has been consistent so far, stressing common-sense precautions over panic, and a bit of, as Levin put it, “hoping for the best but planning for the worst.”

Crunching the Numbers

It is possible that the worst may turn out to be … well, not as bad as some fear.

While the latest reports put the COVID-19 mortality rate around 3.4%, significantly higher than the 0.1% death rate from the flu in the U.S., that may drop over time because it reflects only reported cases, and the majority of people who contract the virus are either asymptomatic or develop mild, cold-like symptoms — and, if they don’t seek medical treatment, they’re not counted in the mortality equation.

Look at it as a fraction, said Dr. Armando Paez, an infectious-diseases specialist at Baystate Medical Center. The medical community knows the numerator — the number of reported deaths. But it has no idea right now what the denominator — the number of infected people — really is.

“The focus with something like this, first and foremost, is to be able to prevent the spread of any respiratory disease — to promptly identify any potential cases and care for patients who may come into contact with it, as well as protect our own healthcare personnel and communicate to the community how best to stay healthy.”

“With the report of mortality risk, you don’t know the denominator, because asymptomatic cases and mild cases might not reach the attention of medical practices, and those won’t be reported,” Paez told HCN.

Writing in Slate last week, Dr. Jeremy Faust, an emergency physician at Brigham and Women’s Hospital in Boston, noted that, when H1N1 emerged in 2009, early mortality estimates were many times greater than the eventually accepted rate of 1.28%. Other epidemics have seen a similar evolution in mortality reports, as the medical community better understands how many people are actually infected.

“The more information we have, including the ones who aren’t sick at all, the better sense we’ll get of this infection,” Paez added. “People ask, ‘what will happen to me, and what are the risk factors can lead to a more serious outcome?’ We don’t know everything yet — our knowledge is based on what’s reported.”

Still, hospitals have to prepare for all contingencies, even worst-case scenarios.

“We really don’t know how it’s going to play out, and there is the potential for it to be severe,” Levin said, partly because the virus is so easily transmitted and because hospitals aren’t currently able to test specifically for COVID-19. Testing to detect the virus was initially only performed at the CDC, and recently the Massachusetts Department of Public Health has also received approval to perform the tests.

“While the Massachusetts Department of Public Health has said the risk remains low in Massachusetts, the Centers for Disease Control and Prevention has indicated that an outbreak in the United States remains possible,” said Dr. Sarah Haessler, an epidemiologist and infectious disease specialist at Baystate Medical Center.

Signs of a possible outbreak in the U.S. have already begun; as of March 4, there were more than 130 confirmed cases of COVID-19, and 11 deaths, across at least 14 states, and cases of community-acquired transmission had been identified on the West Coast.

“We remain on alert in Western Massachusetts for patients who have a history of travel to one of the affected areas or contact with someone who has a confirmed COVID-19 infection,” Haessler noted.

Be Prepared

Meanwhile, the CDC notes that there have been 32 million cases of the flu, several hundred thousand hospitalizations, and around 18,000 deaths in the U.S. this flu season. Still, flu is the devil we know, and the sheer uncertainty posed by coronavirus — after all, no one really knows the exact impact of an epidemic — has people on edge.

“We encourage people not to panic, not to hoard, but to be prepared,” Levin said. “Clean your hands, clean surfaces, use common sense when you’re out and about, and don’t be around people who are sick.”

The state Department of Public Health outlines some of those common-sense precautions, and they parallel the recommended steps for avoiding colds or the flu: wash hands often with soap and warm water for at least 20 seconds, avoid touching one’s eyes and face, clean things that are frequently touched (like doorknobs and countertops) with household cleaning spray or wipes, cover coughs and sneezes with a tissue or the inside of the elbow, stay home when feeling sick, and stay informed.

“It’s a virus — it’s similar to the virus that causes common cold in that it spreads by droplets from a sneeze or cough,” Levin said, adding that the virus might live on surfaces for up to nine days at room temperature. “You’re sick and put your hand on the counter, someone comes by and puts their hand on the counter, and when they touch their nose or mouth, it can be transmitted that way. So keep surfaces clean. You don’t need anything fancy — soap and water or alcohol-based gel will kill the virus.”

While the majority of infected people may feel OK to be out in public, Levin told HCN, there’s a danger in exposing more vulnerable populations, which include older people and those with heart or lung issues and other chronic health problems.

“For most people, this disease will manifest as a cold or cough, but in some people it may be serious; for the elderly or immunocompromised people, it’s a risk for them. We want to protect our most vulnerable patients.”

That might pose challenges for schools, businesses, and other places where people gather if COVID-19 does sweep the country, she added. “In an epidemic situation, we’re not going to want those people to come to work.”

Common signs of COVID-19, which can begin in as little as two days or as long as two weeks after exposure, include respiratory symptoms, fever, cough, and shortness of breath. More serious cases of the infection can cause pneumonia, severe acute respiratory syndrome (SARS), or kidney failure. While some coronavirus symptoms can be confused with influenza, flu symptoms include fever, cough, sore throat, and body aches.

“Just like other upper respiratory viral infections, the typical recommendation to prevent transmission to other people is stay home if you’re sick,” Paez said, in addition to those recommendations about washing hands and surfaces.

“If the patient gets worse, or has difficulty breathing, they need to see a physician or go to the hospital to be further evaluated,” he went on. “Right now, there is no treatment for COVID-19, but there are treatments being investigated. So it’s mostly support when the patient gets to the hospital, like respiratory support.”

Ready for the Surge

Roose said Mercy prepares for a novel infection like COVID-19 in a number of ways. When news arises of a possible large-scale infection, “we organize a multi-disciplinary team to monitor the evolving situation, align our guidance and activities with the CDC, and activate a robust preparedness plan, which includes many key elements.”

That plan is a multi-faceted effort, to be sure.

“The focus with something like this, first and foremost, is to be able to prevent the spread of any respiratory disease — to promptly identify any potential cases, as well as care for patients who may come into contact with it, as well as protect our own healthcare personnel and communicate to the community how best to stay healthy.”

Haessler noted that many patients who present at Baystate Health facilities with respiratory symptoms are evaluated for viral infections using nasal-swab testing capable of detecting 20 different pathogens. The results may include one of several types of human coronavirus that commonly cause respiratory infections in the U.S.

“The good news is that, while the virus can be deadly, the vast majority of patients who develop this new coronavirus will have mild symptoms,” she said. “Most people get infected with one or more of these common coronaviruses at some point in their lives.”

She was quick to add that the virus causing COVID-19 is not the same as these common coronaviruses, and patients suspected or confirmed to have COVID-19 will be evaluated and cared for differently than patients with common coronavirus.

In the coming days, the medical commnity will know more, but for now, Levin told HCN, common sense — not panic — should rule the day. But hospitals do have some concerns.

“If it becomes a big epidemic, supplies will be an issue. Right now, we have plenty of supplies, but some come from China, and people are hoarding, so there’s a lot of concern whether it will be enough if it gets bad. Hopefully it won’t,” she said. “We’re prepared for a surge in capacity, and we’re preparing as best we can.”

As this story continues to evolve, that’s good advice for everyone.