Tag Archives: Coronavirus

Thoughtless, or selfish, that is the question.

(Personal photos Twitter/WhatsApp)

Shakespeare once wrote, “To be, or not to be, that is the question.” Today, we must ask a different question: “Are people thoughtless, or are they simply selfish?”

Despite orders for social distancing and self-isolation to mitigate transmission of COVD-19 in virtually every country, crowds continue to gather in public places, shop in large numbers, and fraternize in neighborhoods throwing Coronavirus block parties. This weekend, the Municipal Fishmarket at The Wharf, in Washington DC, was packed with hundreds of people until the police intervened to shut it down. Even in Dhaka, Bangladesh, millions returned to work until the government issued an official country-wide lockdown, and at a Walmart superstore in Yreka, California, a woman coughed and spat at an employee who asked her to back away at the check-out counter.

How many deaths does it take before people come to their senses? To paraphrase Bob Dylan, “The answer, my friend, is blowing in the wind. The answer is blowing in the wind.”
 
Dr. Deborah Birx, Ambassador-at-large and Coordinator for US Government Activities to Combat HIV/AIDS, is also a vital member of the US Government’s Anti-Coronavirus Taskforce. “The next two weeks are extraordinarily important,” she said on Saturday, April 4. “This is the moment not to be going to the grocery store, not going to the pharmacy, but doing everything you can to keep your family and your friends safe…”

“But I have a family of four to feed,” whined one friend.
“I love food too much,” said another. 
Both are justifying their numerous trips to buy groceries this week.

Neither of my friends is thoughtless. In fact, I have often admired their common sense. This leaves me with only one conclusion; but, what do I do with such information. Do I have a moral duty to persuade them to act responsibly because I am a doctor, or might I simply point out that we are a village, and we will win, or go down together. For all of us, regardless of our profession, this is a defining moment in history. Each and every one of us will recall where we were and what we were doing during this global crisis. Irrespective of our individual roles and responsibilities, we are accountable to each other.

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Overcoming Uncertainty

Screenshot courtesy H. Colt

A few days ago, Andreas Voss, the President of the International Society of Antimicrobial Chemotherapy, posted an advisory1 stating the controversial paper published in IJAA on the favorable effects of Hydroxychloroquine and Azithromycin in patients with COVID-19 infection2 did not meet the journal’s scientific standards. Meanwhile, countless physicians on the frontlines prescribe these drugs. Many also prescribe hydroxychloroquine for their friends and families. Others take it prophylactically. Last week, The Medical Board of California issued a statement reminding doctors that “inappropriately prescribing or dispensing medications constitutes unprofessional conduct in California”3.

     I do not advocate for or against uncertain treatment strategies in these tenuous and rapidly fluid times. After all, COVID-19 also prompts debate about issues such as management algorithms for ventilatory failure, indications for intubation, frequency of diagnostic testing, triage protocols, handling non-COVID-19 patients, and which personal protective equipment is most reliable.

The terrain is challenging, in part because this is the first time practitioners, regulators, and hospital administrators face a crisis of this magnitude. Those of us who were on the front lines throughout the AIDS epidemic have retired or are close to retirement. Some who knew the uncertainties of newly discovered diseases such as Hantavirus in the American West, contamination of our hospitals’ water systems with Legionella, and the surprising outbreak of Cholera in 1990s’ Latin America may now be in leadership positions with different agendas. Others might have been relegated to jobs with lesser responsibility or removed from decision-making positions where they can make a difference in today’s epidemics. 

     How else might we explain why many recommendations provided after the global health care threats of SARS, H1N1, and MERS pandemics earlier this century were ignored and underappreciated. And 40 years ago, AIDS also taught us a painful lesson that has been only partially learned; that a deadly disease somewhere can quickly spread everywhere.

     There is no doubt our international community has made great strides since then. We have improved in regards to predictions and disease modeling, risk assessments and surveillance, outbreak detection, containment strategies, pathogen characterization, and public health interventions, but we have far to go. 

     Let’s hope the COVID-19 pandemic serves to overcome whatever uncertainties exist in our ranks. Then, health care providers in the front lines can take a greater role in persuading hospital administrators and government officials to invest more in protecting our future.

References

1. https://www.isac.world/news-and-publications/official-isac-statement.
2. Gautret P, Lagier JC, Parola P et al. Hydroxychloroquine and azithromycin as a treatment of COVID-19: results of an open-label non-randomized clinical trial. Int J Antimicrob Agents. 2020 Mar 20:105949.
3. Medical Board of California, April 2, 2020. Statement Regarding Improper Prescribing of Medications Related to Treatment for Novel Coronavirus (COVID-19.
4. United Nations Coordinated Appeal. Global Humanitarian Response Plan: COVID-19, April-December, 2020.



Whatever it takes

Photo courtesy H. Colt

Monitoring WhatsApp posts from more than 7000 physicians in 60 countries is disheartening. Lack of personal protective equipment(PPE), the propagation of contradictory or obviously false information by administrative leaders, unclear instructions, and orders to refrain from sharing information about triage, the poor availability of isolation rooms, ventilators, negative pressure procedure suites, and PPE do not inspire confidence. There is something wrong when health care workers (HCW) desperately design and build their own face-shields and patient isolation hoods, or when a nonprofit accreditation organization such as the U.S. Joint Commission issues an order permitting HCWs to bring their own PPE from home in order to overcome the paucity of PPE in the workplace1

     Preliminary data from China, Italy, Spain, and the United States suggest the current in-hospital infection rate of COVID-19 in HCW is up to 20%2-4. This is similar to what happened during the SARS, H1N1 Influenza A, and MERS pandemics earlier this century. Contributing factors include low awareness, lack of early suspicion, particularly of asymptomatic patients able to carry infection, and poor implementation or compliance with appropriate infection control strategies.

     Sadly, HCW are no strangers to the risks of occupation-related lung infections. Tuberculosis, is a known occupational hazard since the 1950s, with studies reporting a greater than average risk to become infected with Mycobacterium tuberculosis and to develop TB disease5. In one report, HCWs were six times more likely to be hospitalized for drug-resistant TB than the general population6. In 2002, Severe Acute Respiratory Syndrome (SARS-CoV) affected more than 8000 patients in 26 countries, killing more than 800 people and infecting at least 21% of health care workers involved in their care7. In 2009, among confirmed and probable cases of novel Influenza A (nH1N1) reported to the CDC less than 3 months after the start of that pandemic, 4% were in HCW, and occurred in situations where the use of PPE was not in compliance with CDC recommendations8. Three years later, Middle East Respiratory Syndrome Coronavirus (MERS-CoV) infection quickly spread to 27 countries. Thirty of the first 161 cases were health care providers9. With a mind-numbing 34.8% crude case fatality rate, MERS eventually affected up to 19.6% of HCW exposed in the workplace10.

     HCWs know that every encounter with a known or suspected COVID-19 patient exposes them to viral loads in the form of droplets, fomites or aerosols. This puts them at risk for weeks of quarantine, often debilitating illness, and death. Five years ago, Bill Gates gave a clairvoyant TED talk called The Next Outbreak? We’re Not Ready, in which he outlined the world’s lack of preparedness for a pandemic11. What he did not address was how to balance a HCW’s ethical responsibility to provide care, with an employing organization’s responsibility to assure their safety12. Do HCW workers have a moral obligation to risk their lives in an environment they know is unsafe, and what if they suspect the rules and regulations proposed by their administrators are inconsistent with practices that are possible in the front lines? This double bind is what HCWs face every day.

     Reading reports from the Institute of Medicine after the SARS, nH1N1, and MERs pandemics sadly demonstrate that unpreparedness is repeated13-15. If telling my first responder brother to “quit his job,” or asking my Critical Care doc sister “to be ready to take one for the team,” are both morally unacceptable, then all we can ask is that HCWs take personal responsibility to assure their own safety and that of their teams. Whatever it takes.  

References     

  1. https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/infection-prevention-and-hai/covid19/public_statement_on_masks_from_home.pdf
  2. https://www.reliasmedia.com/articles/145920-more-than-3000-hcws-infected-with-covid-19-in-china.
  3. https://www.nbcnews.com/news/us-news/health-care-workers-see-wave-coronavirus-coming-their-ranks-n1174271
  4. COVID-19: Protecting Health care workers. The Lancet editorial March 2020;395 pg922.
  5. Baussano I, Nunn P, Williams B et al. Tuberculosis among health care workers. Emerg Infect Dis 2011;17:488-494.
  6. O’Donnell MR, Jarand J, Loveday M, al. High incidence of hospital admissions with multidrug resistant and extensively drug resistant tuberculosis among south African health care workers. Ann Intern Med 2010;153:516-522.
  7. Chan-Yeung M. Severe Acute Respiratory Syndrome and Healthcare Workers. Int J Occup Environ Health 2004;10:421-427.
  8. MMWR June 19, 2009;58(23):641-645.
  9. Perl TM, McGeer A, Price CS. Medusa’s Ugly Head Again: From SARS to MERS-CoV. Ann Intern Med. 2014;160:432-433.
  10. WHO MERS-CoV Global Summary and Assessment of Risk. July 21,2017.
  11. https://www.youtube.com/watch?v=6Af6b_wyiwI.
  12. McDiarmid M. Advocating for the Health Worker. Annals Global Health 2019;85(1):16(1-4).
  13. Emerging Viral Diseases: The One Health Connection: Workshop Summary (2015). National Academies Press. Available at http://nap.edu/18975
  14. Respiratory Protection for Healthcare Workers in the Workplace against Novel H1N1 Influenza A: A letter report (2009). The National Academies Press. available at http://nap.edu/18975
  15. Learning from SARS: Preparing for the next disease outbreak: Workshop Summary (2004). The National Academies Press. Available at http://www.nap.edu/catalog/10915.html.