19 Things We Need to Conquer the COVID-19 Pandemic: Part 2

By Andrew L. Concoff, MD, FACR, CAQSM

In Part II of this series, we continue the countdown of the list of what we need to overcome the challenges of the COVID-19 Pandemic. We seem at this stage in the outbreak to be at an awkward transition phase. Some communities have already borne the brunt of the Pandemic, and case numbers are beginning to fall. Others are just now coming into harm’s way. Still, others have been largely spared. Yet if prior pandemics are any guide, we are not yet out of the woods.

We have now lost more US lives to COVID-19 than died in the Vietnam War, and we have reached 1 Million confirmed cases in the US. Vigilance and adaptability would appear to be the orders of the day. We have always been a resilient nation that has risen to such challenges. Accordingly, in the interest of doing so again, here are the next five societal goals needed to evolve our culture through the Pandemic.

15. Development of efficient surge systems to deliver construction, bolter supply chain and speed distribution of required resources tailored to the variety of affected American communities

  • Resources:
    1. Personal protective equipment (PPE)
    2. Ventilators
    3. Dialysis units
    4. Hospital beds
    5. Health care providers
    6. Medications
      • Albuterol
      • Antivirals
      • Convalescent serum
      • Novel medications for trials
  • Distribution of resources remains a priority through centralized, data-driven apportionment
  • Coordinated local, regional, and interstate distribution and redistribution of resources by priority of need
  • Mobilize “strike-teams” of providers to hotspots
  • Seamless integration between early aggressive surveillance measures in communities undergoing relaxation of social distancing and distribution of resources
    1. Aggressive surveillance testing of symptomatic and asymptomatic populations
    2. Adoption of predictive, proximate indicators of impending spikes in prevalence to limit time in exponential spread prior to re-instating social distancing  
  • We have entered a complex phase of hotspot generation that differs according to community population density
    1. Urban areas like New York City have been the most affected to date likely because of population density and in-bound travel. They have now crested the first wave
    2. Many rural communities wherein social distancing measures have been more lax are just now beginning to experience a delayed first wave
    3. Urban communities will experience a second wave in conditions where social distancing is relaxed too quickly, if outbreaks are not recognized through adequate surveillance testing during relaxation of social regulations, or if micro-populations of high spread are not identified36
  • The ability to deliver portable, turn-key, clinical trial enrollment to newly affected communities to incorporate patients through ready access into trials of the latest medications

14. Effective Further Transition of U.S. Healthcare to Telemedicine41

  • Effectiveness
    1. Identification of best practices and efficiencies for medical offices
    2. “Forward triage”:
      • Patient selection: identification of specific complaints by specialty and subspecialty that are not appropriate for telemedicine and that require in-person visits
      • Identification of telemedicine “red flags” that warrant transition to in-person evaluation or urgent/emergent care
    3. Leverage timely laboratory testing providing results at the time of visit as an adjunctive source of disease activity and/or drug toxicity data for telemedicine visits
  • Maintenance of reimbursement equality with in-person visits to sustain practice viability
  • Encourage patient education and adoption to optimize telemedicine visits
    1. Development and dissemination of specialty-specific physical examination maneuvers as diagnostic aids
    2. Pre-visit distribution of validated self-assessment instruments for incorporation into EMRs to limit disruptions to assessments of disease control
  • Development of novel, companion technology and equipment to replace vital elements of the physical examination including palpation, auscultation, and percussion
  • Much of routine care has vanished during the pandemic – it will likely return only gradually through a transition period dominated by telemedicine
    1. During this period, the effectiveness of telemedicine delivered and the amount it is availed by patients will determine the quality of all non-COVID-19 care provided

13. Nuanced social distancing policies designed to minimize spread, optimize adherence and minimize behavioral health and economic harm

  • Coherent policies for institution and relaxation of regional social distancing across the county, city, and state borders that are commonly traversed
    1. Lack of coordination across borders simply encourages travel to less restrictive areas34
    2. Uniform, data-driven approaches27 to determine:
      • Timing for initiation of policies
      • Timing of phased relaxation of policies
        1. Data-driven thresholds, rather than calendar-mandates
        2. Development of location-specific phases of social distancing restriction intensity
  • Appropriate limitations of travel with mandatory self-quarantines upon crossing borders into local or regional hot zones
  • Widespread testing of broad populations to provide data to guide changes to social distancing policies
    • Until adequate testing data is available with which to monitor the impact of relaxation policies, rigorous social distancing should be maintained
      1. Clear evidence now exists for the favorable impact of early, aggressive social distancing35
      2. Clear evidence exists for the negative impact of overly aggressive relaxation of social distancing policies36
  • Social distancing programs must include behavioral health outreach to:
    1. Encourage adherence with social distancing
    2. Provide stress management options
    3. Encourage attention to sleep hygiene
    4. Address increased risk of suicidality37
      • Sources:
        1. Isolation
        2. Job loss/economic distress
        3. COVID-19-related anxiety
  • Local penalties for violations of social distancing that function as an effective deterrent must be determined and enforced
  • Economics of social distancing policy are critical considerations but must be secondary to public health concerns
    1. Least restrictive policies that ensure public safety must be determined
    2. Counterintuitively, research on the 1918 pandemic38 suggests that because the pandemic, itself, is so economically devastating, cities with stronger social distancing measures are rewarded with stronger economic recoveries.  Thus, while pandemics depress local economies, aggressive public health interventions appear not to.   
    3. Overly aggressive efforts at relaxation may prove the costliest approach if a second wave of infections requires the re-imposition of longer-term strict social distancing measures38
  • Easing Social Distancing Regulations
    1. According to the CDC,39 estimated dates by which each state could safely begin relaxing social distancing vary from May 4th through June 15th, although some states have already determined to do so. 
      • Although the CDC estimated that such changes would not be safe until June 15th in Georgia, such measures have already been taken
    2. Gov. Gavin Newsom (CA.) has established six criteria required before responsible relaxation of social distancing policies can occur:40
      • Close monitoring and tracking of potential cases
      • Prevention of infection among high-risk people
      • Preparation of hospitals to handle surges
      • Identification of effective and available treatments
      • The ability of schools, businesses and child-care facilities to maintain social distancing
      • Establish guidelines for when to ask residents to stay home again, if necessary

12. Community-based, public health outreach programs targeting underserved populations

  • Epidemics typically hit hardest among the most vulnerable in society33
  • Outreach programs generate opportunity for the delivery of focused and robust testing, isolation and treatment (when available) at the place where they are most needed – in communities prior to the need for hospitalization16
    1. Tuberculosis outreach as a relevant example
  • Applied per uniform, data-driven criteria to local hotspots that develop as social distancing is relaxed
  • Consistent nationwide criteria for deployment
  • Underserved populations, notably including the homeless, represent a dangerous reservoir for the spread of highly contagious diseases

11. Adoption of standard hygiene rules and innovations at sites of social interaction – defining the new normal in the public space

  • Mandatory facial covering when in public locations where maintaining social distancing is difficult30
    1. “No naked faces”
  • Restaurants and bars:
    1. Service staff at bars and restaurants must initially wear masks and gloves given risks imposed by asymptomatic, droplet-based spread of SARS-CoV-2
    2. Tables six feet apart
      • Will limit the profitability of some establishments and the viability of others
  • Offices:31
    1. Some workers will not return to the office
      • An estimated 30 percent, rather than the pre-COVID 4 percent, may continue to work from home
    2. For those that do, the environment will be different:
      • Densification, the movement toward using progressively less space per worker is dead.
        • “Six Feet office” is a new office design concept that aims to maintain social distancing at work
      • Innovations, including automation and vocal commands, will limit contact with high-touch surfaces from door handles to elevator buttons
      • Each face-to-face meeting will need to be justified
  • “Screen-to-enter,” point-of-service screening policies for high-traffic public spaces including grocery stores
    1. Fever screening is of limited value outside of medical facilities:32
      • Limited Accuracy
        1. False negatives: 
          • Failure to identify asymptomatic infection (responsible for 44% of infections with SARS-CoV-2) and related risk of spread
        2. False positives: 
          • Identification of patients with fevers from alternative sources
    2. Provision of hand sanitizer or glove distribution when available
    3. Routine disinfection of high-touch surfaces
    4. Rapid diagnostic tests20 or serologic-test-based “immunity” cards may eventually serve in this capacity in medical facilities

To be continued in part 3 – #10 to #6

Stay safe, stay healthy, stay United. 

REFERENCES:

30.  Centers for Disease Control.  Use of cloth face coverings to help slow the spread of COVID-19.  https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/diy-cloth-face-coverings.html; accessed 4/6/2020

31.  Molla R.  This is the end of the office as we know it. Vox, 4/14/2020; https://www.vox.com/recode/2020/4/14/21211789/coronavirus-office-space-work-from-home-design-architecture-real-estate

32.  Rauhala E.  Some countries use temperature checks for coronavirus. Others don’t bother. Here’s why. Washington Post, 3/14/2020;  https://www.washingtonpost.com/world/coronavirus-temperature-screening/2020/03/14/24185be0-6563-11ea-912d-d98032ec8e25_story.html

33.  Lay LS et al.  COVID-19 in humanitarian settings and lessons learned from past epidemics.  Nature Medicine, 2020; https://doi.org/10.1038/s41591-020-0851-2

34.  Fry H & Pineda D.  Newport beach may close beaches on weekends after heat wave draws thousands; https://www.latimes.com/california/story/2020-04-27/newport-beach-may-close-beaches-on-weekends; Los Angeles Times, 4/27/2020

35.  Fowler GA, Kelly H & Albergotti R.   Social distancing works. The earlier the better, California and Washington data show.  The Washington Post, 4/1/2020; https://www.washingtonpost.com/nation/2020/04/01/lockdown-coronavirus-california-data/

36.  Griffiths J.  Singapore had a model coronavirus response, then cases spiked. What happened?  https://www.cnn.com/2020/04/18/asia/singapore-coronavirus-response-intl-hnk/index.html; CNN World, 4/19/2020; accessed 4/27/2020

37. Dastagir AE. ‘Isolation is a big trigger’: feelings of suicide are amplified amid a pandemic.  USA Today; 3/23/2020; https://www.usatoday.com/story/news/nation/2020/03/23/coronavirus-pandemic-isolation-fear-job-loss-triggers-suicide/2871949001/

38.  Correia S, Luck S & Verner E.  Pandemics depress the economy, public health interventions do not: evidence from the 1918 flu.  https://ssrn.com/abstract=3561560 or http://dx.doi.org/10.2139/ssrn.3561560 ; March 30, 2020.

39.  Fink J.  When can states start relaxing social distancing? Here’s what projections say.  Newsweek, 4/20/20.   https://www.newsweek.com/when-can-states-start-relaxing-social-distancing-heres-what-projections-say-1499028

40.  Feuer W.  California Gov. Gavin Newsom unveils guide to lifting state’s coronavirus restrictions. CNBC, 4/14/2020.   https://www.cnbc.com/2020/04/14/california-gov-gavin-newsom-unveils-guide-to-lifting-coronavirus-restrictions.html

41. Hollander JE & Carr BG.  Virtually perfect?  Telemedicine for COVID-19.  NEJM, 2020; DOI: 10.1056/NEJMp20035

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