Labcoats vs. the coronavirus

It was January 30th, less than two months ago. The World Health Organization declared the outbreak of the coronavirus—or COVID-19—a “public health emergency of international concern.”

Then, on March 11th, barely a week ago, the WHO characterized COVID-19 as a pandemic. COVID-19 was first detected in China in December of last year, and now has been detected in more than 120 countries around the world.

Pandemics are first identified with an investigation phase. Thereafter, just like with the WHO’s announcement on the 11th, pandemics are officially “recognized” and “initiated.” At this time, the disease is in its acceleration phase, which will be followed with a deceleration phase where we start to see a decrease in illness. Of course, different countries and even different communities within those countries can be in different phases of the pandemic at any given point in time.

The death toll from COVID-19 is now well over 6,000 worldwide.

The complete clinical picture of COVID-19 isn’t known yet, because (as its name would suggest) the “novel” coronavirus is newly discovered after a recent transmission to humans from an unknown animal source. What we do know is that reported symptoms have ranged from very mild to severe, requiring ICU care, including the death toll that is mounting country-to-country.

It’s estimated that serious illness occurs in 16% of COVID-19 cases, particularly in older people and any patients with severe underlying health conditions. It’s almost 4% of COVID-19 cases that result in death.

So, what can we do?

On a personal basis, practicing basic hygiene and social isolation is the extent of actions we can take. No matter how many rolls of toilet paper you stash in the closet, little else will help you more than washing your hands and creating as much social distance as you can.

The labcoat still has something to say about this pandemic. We don’t mean that the white lab coat will protect you from the virus itself. Instead, we’re talking about the STEM community and the research underway right now in every country around the world to understand this virus.

Many of us will be socially isolated in coming weeks. Many of us already are. Hundreds of millions will be quarantined—but we aren’t alone. We as a species are an inherently curious community of born researchers. We’re discovers and we’re problem-solvers. The number of career paths in STEM fields is a testament to that, and it’s what will get us through this.

Rapid research is how we know what we do now, and how we’ll continue to get to the source and the solution of COVID-19. This virus barely made its first appearance in China last four months ago, but science and medical professionals have made progress and pushed through.

So, what are we learning with all this research? Who is researching what? That’s what we’re here to answer today. Buckle up to see a few highlights of what’s underway right now in the world of the labcoat vs. the coronavirus.

 

Study 1: Recommendations for the care crisis in hospitals and clinics

A recent paper by Jianfeng Xie et al talks about the lack of critical care resources available for medical professionals fighting COVID-19 in the countries with the biggest oubreaks. Not only are doctors, nurses and support staff battling the virus itself, but this paper discusses the 15% of patients who developed severe pneumonia, in particular, in the Wuhan province of China as a result of the illness. Of those patients, 6% needed ventilator support. The need for care exponentially outweighed the capacity.

With 1,000 patients in China needing ventilators and another 120 new patients a day in Wuhan testing positive for the virus at the start of this year, the 600 ICU beds in the Wuhan City Hospital were never going to cut it.

The fastest and most effective response is to create ICU beds from general beds wherever possible was to transform large portions of general hospitals to critical care hospitals. In Wuhan, this decision resulted in 2,500 ICU beds specializing in patients with severe cases of COVID-19.

 

Study 2: Reserve medical supplies and public health emergencies

It’s one thing to go shopping for your designer lab coats when it’s for the “normal grind” of your medical or other STEM-based career. It can be a real joy to shop for the fitted lab coat that you’ll sport at your upcoming conference, or to stock up your closet with a lab jacket for every day of the week. (Of course! Who doesn’t want to be as hygienic as possible?)

Other medical supplies, however, are in trouble today. Recent research into the Chinese Government’s response to COVID-19 focused on the enormous shortage of emergency medical supplies, including even personal protective equipment like labcoats, biohazard suits and medical masks.

This factor alone has affected the progress of controlling and responding to the epidemic.

We’ll get through this one, but there will be future pandemics. This lesson here today is the opportunity for the international community to emphasize improving our systems of emergency reserves of medical supplies. International cooperative programs can jointly deal with public health emergencies, too, building a faster and more effective way to combat pandemic illness in the future.

 

Study 3: What is the best risk-based strategy to select the right personal protective equipment for COVID-19?

A recent study done and published by Rachael M. Jones et al explores personal protective equipment (PPE) as a primary strategy to protect heal care personnel from COVID-19 and the other infectious diseases that have surged as a complication of the novel virus.

To do this, the study explored the transmission pathway of the disease to anticipate the exposure level and then select the appropriate PPE. Current guidance for this process is limited, and so Jones et al determined that a risk-based approach to select and evaluate PPE was most appropriate, including assessments of:

  1. A job hazard analysis
  2. A disease hazard analysis
  3. Selection of PPE
  4. And evaluation of PPE

 

Study 4: Duration of quarantine with severe symptoms of COVID-19

Andrea Lombardi et al asked a question that had to be answered: while self-inflicted quarantine has been recommended and even required to citizens of more than a dozen countries suffering the greatest numbers of COVID-19 cases, what duration of quarantine is appropriate for this novel virus? Particularly in the case of patients who suffer severe symptoms of the infection, how long should people remain in isolation?

First, it’s crucial to understand the incubation process of the virus. After infection, COVID-19 symptoms appear only after 3-5 days. 80% of those infected experience a mild disease, but 16% experience severe symptoms and the remaining 4% will require serious support and end up in the ICU.

These numbers, the study explain, clearly explain why any measure possible should be considered to avoid further diffusion of the virus, particularly to avoid saturation and the collapse of health care systems.

Isolation (or quarantine) of those affected, thus, coupled with proper use of personal protective equipment, are the main blocks to further transmission.

The study found that the 14-day quarantine applied to subjects coming from endemic areas or those who have had contact with confirmed cases is adequate to demonstrate whether or not that person will begin to show symptoms of the possible infection.

It’s worth highlighting that the ongoing outbreak in Italy has been linked to a single infected patient who accessed a community hospital in the north of the country where he transmitted the virus to other patients and health-care operators. And now, as of mid-March, Italy has had more than 25,000 confirmed cases.

The quarantine of patients in hospitals is also necessary, though it’s put a strain on already-limited PPE stores. To determine the adequate amount of time, previous discussions around the viral shedding of COVID-19 are not enough. The data needed required an assessment of infectivity, which is exactly what this study set out to do.

The findings showed that the viral load above the minimum detection limit was detected between 14 and 25 days after the onset of symptoms, and 11 to 13 days after the first detection.

 

Study 5: What is the “biopreparedness” of hospitals for the current case load?

Saskia Popescu studied the recent analysis of 138 hospitalized patients in Wuhan, China to collect evidence for the need for greater investments into hospital biopreparedness. In general terms, this refers to the overall infection prevention efforts in accordance with the resources available.

With that analysis in mind, further resource found two factors that are most relevant to the health care preparedness for this disease:

  1. First, 26% of patients required admission to ICU, reflecting preparedness (or the lack thereof) to keep them stable before conditions escalated
  2. Second, 41% of COVID-19 cases were related to health care transmission.

Those patients requiring intensive care inherently burden the system more in both supplies and personnel, not to mention the greater length of stay. This is not a unique finding, but in the case of COVID-19 is a direct reflection of the biopreparedness for this pandemic outbreak.

In the worst of cases, such as with the findings in this analysis, hospitals can easily act as amplifiers for greater transmission for the disease. This vulnerability was highlighted in 2003 as well with the SARS outbreak in Toronto. Busy emergency departments, days in isolation, and improper PPE fueled the spread of the disease.

 

Study 6: Are air purifying respirators a solution to protect health care workers?

We have to protect health care workers or the already-over-burdened health care system will collapse. Lisa M. Brosseau asked whether air purifying respirators could be a solution to protect doctors, nurses and other hospital workers.

This question has been a “long time coming.” COVID-19 marks the third time in less than 20 years that we see a global concern about a novel coronavirus attaching the respiratory system, in particular. SARS was first reported to the WHO by China in 2003, and one third of those cases were among health care workers at that time. By the end of the outbreak, more than half of the SARS cases were health care workers or medical students.

For many years after the SARS outbreak, there was plenty of debate within medical and infectious disease academic communities about how to best protect medical workers from this respiratory mode of disease transmission. Aerosols had to be at least partially responsible for the ease with which SARS was transmitted person-to-person. Later epidemiologic data proved that this was true, and that it was, in fact, the case-risk factor for transmission of SARS from infectious patients to medical personnel.

And this could have been slowed considerably with the proper use of personal protective equipment and with isolation of infected patients.

In May 2012, it was MERS that spent two years circulating in the Middle East until cases were reported elsewhere. This was another aerosol-transmitted disease, and patients were also undergoing aerosol-generating procedures like intubation and bronchoscopies. But the disease was not as infectious as COVID-19.

As a consequence of all this data, this paper argues that health care workers should be provided with fit-tested filtering facepiece respirators at a minimum when caring for COVID-19 patients. And, fortunately, this isn’t something readily available at the grocery store, such that shortages though there will be, at least the masses cannot rush to buy in bulk and hurt the medical community’s chance at safely doing their job.

To protect health care workers from infectious particles, particularly from those patients experiencing severe symptoms of the novel coronavirus who require procedures that are ultimately aerosol-generating, powered air purifying respirators (a higher degree of protection) are recommended.

 

This research and so much more is happening all around the world. Specific questions are getting answered, not only to understand the origins and the implications of COVID-19, but to ensure that we can respond accordingly.

We’re in this thing for a while. Even in the most optimistic estimation, a vaccine might not be ready for another 12, 14 or 16 months. In the meanwhile, rapid research is taking place in the STEM community around the world.

The white lab coat will continue to designate doctors, nurse practitioners and other medical professionals at hospitals which are currently understaffed and weighed down with more patients than they have ever had. And in the lab, other science professionals are studying specific questions around this pandemic to get specific points of action to slow down infection and treat patients more safely and efficiently.

Keep your eyes out for more topics and news around this subject. Dr. James will be compiling more information for you soon.

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