COVID-19: A Call for Science-Informed Management
Author: Prof. Dr. Kristi L. Koenig, MD, FACEP, FIFEM, FAEMS (EMS Medical Director, County of San Diego, Health and Human Services Agency)
An obscure article[i] in the South China Morning Post about a cluster of cases of “pneumonia of unknown origin” that was linked to a seafood and live-animal market in the central Chinese city of Wuhan caught my eye in late December 2019. I thought, “Hmmm, this bears watching!” At that time, quoted experts opined that the situation could likely be contained. Unlike the memorable 2003 Severe Acute Respiratory Syndrome (SARS) outbreak, no human-to-human infection transmission had been reported and no medical staff had yet contracted the disease. As the situation unfolded, however, containment was not achieved. The mystery illness, due to a novel coronavirus causing a disease eventually named COVID-19, rapidly spread to become the sixth ever World Health Organization-declared “Public Health Emergency of International Concern.” Intensified travel and celebrations during the Chinese Lunar New Year, coupled to an overlap with influenza season — with patients presenting with similar symptoms — made it extraordinarily difficult to detect and contain this novel virus.
As with any novel virus, key disease features were initially uncertain, making the application of evidence-based strategies to protect lives especially formidable. Psychosocial, geopolitical, and economic influences — as well as challenges in providing consistent and accurate communication, particularly in an age of widespread social media use — further complicated containment and management strategies.
Effectively managing a newly emerging infectious disease requires clarifying its characteristics as early as possible.[ii] This includes creating a case definition. For COVID-19, the case definition has already changed multiple times, making it onerous to accurately identify and tally case counts. Additionally, the criteria to identify a “patient under investigation” (PUI) has morphed several times and, given that sustained community transmission is becoming more prevalent in countries around the globe, may become so broad as to become almost meaningless.
Key disease characteristics needing rapid identification include:
- Is the virus transmissible prior to symptom onset?
- Is human-to-human transmission possible and, if so, what is the R0 (i.e., how contagious is it)?
- What is the incubation period (lower and upper ranges)?
- What is the sensitivity and specificity of diagnostic testing?
- Are diagnostic tests reliable prior to symptom onset?
- Does a person have immunity after initial infection and, if so, for how long? Is reinfection possible?
- What are the criteria to determine when a patient is no longer infectious? If the virus continues to be detected, does that mean a person is still contagious? Conversely, if a single test is negative, does it rule out the possibility that the patient can transmit the virus to others?
- What type of personal protective equipment is needed for healthcare workers? For the public (if any)?
Each of these disease characteristics has important implications for mitigation strategies. In order to facilitate assistance from the public, they must be kept transparently informed over time as to what is known…and what is unknown. Scientists must educate policy makers about the evolving knowledge base to facilitate evidence-based, informed decisions that match the current state of the science.[iii] There must be flexibility to adjust strategies as the science progresses. This is, after all, a novel virus and we are still unraveling its mysteries.
For example, if a disease cannot be transmitted from person to person prior to symptom onset, such as Ebola virus disease[iv],[v], other types of public health monitoring would represent a more effective evidence-based strategy than the application of quarantine. Conversely, if a disease is transmissible prior to symptom onset, such as measles[vi], quarantine may be an option. Quarantine, however, has many non-medical implications, and therefore is best implemented on a voluntary basis and in combination with robust education for those involved about how to protect themselves and others. Attempts at enforcement of involuntary quarantine are fraught with complexities.[vii]
Much controversy surrounds the unprecedented quarantine attempts during the COVID-19 outbreak, including within China; on selected cruise ships around the world; and in dedicated locations such as military bases and isolated islands in countries that repatriated their citizens from various hot zones. In addition, there remains confusion between “quarantine” (a public health tool used for asymptomatic persons who are infectious) and “isolation” (a different type of separation of people who have disease symptoms).[viii] Obviously, the cohorting of asymptomatic people with symptomatic people is problematic and may expose them to disease.
The phrase frequently used by policy makers “out of an abundance of caution” is not without risk. In fact, many activities in widespread use are unproven and may have unintended negative consequences including:
- Quarantine of the public (can expose uninfected people to infected persons)
- Quarantine of healthcare workers (can result in inadequate staff for both COVID-19 patients and routine patients, including personnel needed to respond to prehospital emergencies)
- Fever screening at airports (results in both over and under identification of infected people leading to anxiety and unnecessary resource use); current information suggests that it is not uncommon for infected patients be afebrile at initial presentation
- Travel bans and restrictions (are inconsistently applied and can negatively affect economies; can inhibit the ability for healthcare workers and supplies to travel where needed to eradicate disease)
- Use of surgical masks or N-95 respirators by the public (could lead to shortages in healthcare settings for healthcare providers who are treating both COVID-19 patients and others, like tuberculosis patients); current evidence suggests masks are ineffective and unnecessary for the public in most situations
- Establishment of “coronavirus” hospitals (most healthcare facilities should be able to manage COVID-19 patients, if staff are appropriately trained and equipped, but a dedicated infectious disease hospital with isolation capacity might make sense in some systems)
As nosocomial infections are increasingly being reported in healthcare settings, it becomes even more critical to apply the widely adopted 3I Tool (Identify-Isolate-Inform),[x] to mitigate spread of the virus and protect healthcare workers as well as non-infected patients.
At this time, it seems clear that community transmission is occurring in many communities around the world. Therefore, we must use our entire toolbox of mitigation strategies including those that create “surge capacity,” specifically the 3S Surge System of stuff, staff, and structure.[xi],[xii],[xiii] Even if we cannot fully contain the virus — an anticipated scenario in the age of global travel for a neoteric disease with an extended incubation period — we can both reduce transmission and delay spread (a so called “flattening of the epi curve”) in order to assist in the preservation of our healthcare system, including its continued ability to care for baseline emergencies.
Furthermore, indirect effects of the outbreak must be anticipated and mitigated. For example, the inevitable substantial impact on the medication supply chain for routine and baseline emergency healthcare, with many drug components being manufactured in China, will likely exacerbate already existing shortages. Critical supplies, such as those needed for personal protective equipment, are already reported to be completely out of stock, which threatens the ability to meet baseline healthcare requirements in addition to the needs of patients infected with COVID-19. Isolation capacity is needed routinely as well as for this evolving situation. Therefore, strategies to create new capacity, while concurrently expanding existing systems, must be implemented.
In addition, we urgently need randomized controlled trials to assess various treatment options, including the use of antivirals and other therapeutic modalities. Surveillance is critical and accelerated development of diagnostics, particularly point-of-care testing, is paramount. Certainly, fast-tracking the creation of safe and effective vaccines, as is being done, is crucial.
In short, we need a global, unified, and evidence-supported strategy that is sufficiently nimble to rapidly adapt as the science evolves. There must be a balance between individual care and population health that benefits the public good. Global collaboration and consistent application of evidence-based actions are urgently needed, rather than a fragmented approach based in part on misinformation, fears, financial considerations, and political influences such as the need for officials to provide the appearance of “doing something.” Application of crisis and emergency risk communication principles is also paramount. Policy makers must heed advice from respected scientists and tune out the noise of self-proclaimed “experts” who have little to no prior experience in emerging infectious disease management. We urgently need evidence-supported mitigation measures that are standardized around the world. Let’s use science to inform our management of COVID-19!
Kristi is the EMS Medical Director, County of San Diego, Professor Emeritus of Emergency Medicine & Public Health School of Medicine Director Emeritus of Public Health Preparedness, Founding Director Emeritus, Center for Disaster Medical Sciences and Founding Director Emeritus, and International EMS & Disaster Medical Sciences Fellowship. A Fulbright Scholar and Fellow of the International Federation for Emergency Medicine, she published a definitive Disaster Medicine text, authored more than 115 peer-reviewed articles, and delivered nearly 500 lectures in more than a dozen countries. Dr. Koenig previously held a 5-year appointment with the federal government as National Emergency Management Director for the Department of Veterans Affairs.
[i] Hong Kong takes emergency measures as mystery ‘pneumonia’ infects dozens in China’s Wuhan city. South China Morning Post. Accessed, Feb 23, 2020.
[ii] Gamage SD, Kralovic SM, Roselle GA. Chapter 8: Emerging Infectious Diseases: Concepts in Preparing for and Responding to the Next Microbial Threat. In: Koenig K, ed. Koenig and Schultz’s Disaster Medicine, 2nd ed. Cambridge, United Kingdom: Cambridge University Press; 2016. Emerging Infectious Diseases: Concepts in Preparing for and Responding to the Next Microbial Threat
[iii] Koenig KL, Schultz C, Runnerstrom R, Ogunseiten O. Public Health and Disasters: An Emerging Translational and Implementation Science, not “Lessons Learned”. Disaster Medicine and Public Health Preparedness 1-2. 2017.
[iv] Koenig KL, Majestic C, Burns MJ. Ebola Virus Disease: Essential Public Health Principles for Clinicians. West J Emerg Med. 2014;15(7):728–731.
[v] Koenig KL. Health Care Worker Quarantine for Ebola: To Eradicate the Virus or Alleviate Fear? Ann Emerg Med. 2014;65(3):330-331.
[vi] Koenig KL, Alassaf W, Burns MJ. Identify-Isolate-Inform: A tool for Initial Detection and Management of Measles patients in the Emergency Department. West J Emerg Med. 2015;16(2):212-219.
[vii] Barbisch D, Koenig KL, Shih F-Y. Is There a Case for Quarantine? Perspectives from SARS to Ebola. Disaster Med Public Health Prep. 2015;9(5):547-553.
[viii] Koenig KL. Evidence Aid. The Quarantine Conundrum: Perspectives for the humanitarian community. Accessed January 24, 2020.
[ix] Koenig KL, Beÿ CK, McDonald EC. 2019-nCoV: The Identify-Isolate-Inform (3I) Tool Applied to a Novel Emerging Coronavirus. Western Journal of Emergency Medicine. 2020. Accessed March 1, 2020.
[x] Koenig KL. Identify, Isolate, Inform: A 3-Pronged Approach to Management of Public Health Emergencies. Disaster Med Public Health Prep. 2015;9(1):86-87.
[xi] Shih F, Koenig KL. Improving Surge Capacity for Biothreats: Experience from Taiwan. Acad Emerg Med 2006 Nov;13(11):1114-17.
[xii] Kaji A, Koenig KL, Bey T. Surge Capacity for Healthcare Systems: A Conceptual Framework. Acad Emerg Med 2006 Nov;13(11):1157-59.