Policy Brief: Rapidly Emerging Crisis: Immediate Action-Items to Address the Novel Coronavirus (SARS-CoV-2/COVID-19) Outbreak in New York

Authors: Dr. Megan Coffee, MD, PhD; Evan Anderson, CEO, INVNT/IP

3.18.20

Executive Summary

The situation of rising COVID-19 caseloads in New York City is rapidly becoming a crisis on the level of the current situation in Lombardy, Italy. Such a situation would be disastrous, and can be mitigated by the rapid imposition of shelter-in-place requirements for residents and the immediate increase of ICU bed capacity and staff, and ventilator, PPE, and generic pharmaceutical supplies in order to reduce infection and transmission. In so doing, authorities will not only drastically reduce mortality in the city itself, but prevent an untenable explosion of disease transmission from New York into other areas, thus acting to protect the country and, specifically, the Eastern Seaboard and the capitol.

Introduction

New York City is facing a COVID-19 outbreak involving community spread in the most densely populated area in the United States. The occurrence and presentation of the illness in New York requires immediate action along a simple set of parameters that will help to avoid a situation of runaway infection and mortality that would equal that of the more pressing outbreaks worldwide. If action is taken soon and coherently, such a situation can be avoided, saving countless lives and avoiding large and unnecessary expenditures.

Explanation

As of 2:51 AM EST on March 18, 2020, it is apparent that New York City and its environs are experiencing community spread of SARS-CoV2 in a dense, urban environment similar to that of European population centers currently undergoing overwhelming stress on local medical systems. This situation is particularly reminiscent of what is currently occurring in Northern Italy. It is therefore critical that action be taken to avoid catastrophic medical consequences comparable to those of the overwhelmed hospital system in Lombardy, by taking immediate and aggressive action to counteract the spread of the disease in the New York area.

According to models and predictions from the COVID-19 response team at Imperial College London, non-pharmaceutical (physical) interventions (NPI) are the main tools available in this emergency scenario. The New York medical system currently has roughly 3000 ICU beds, with 600 open at any given time. In order to meet potential demand, based on the Imperial College London study, indicate that New York city will require an additional capacity of up to 50,000 ICU beds in a short span if not everything possible is done to slow its spread. If NPI are maximally utilized, the Imperial Study still predicts the need for 6000 beds. With this modeling study as a framework for prediction, Governor Andrew Cuomo has already requested an additional capacity of 110,000 beds, with an ICU capacity of 37,000 beds.4 Such a capacity increase will also mean having increased staffing as ventilator care requires high staffing ratios for safe management and care will be less safe, as nursing to patient ratios decrease from 1:1 or 1:2 at baseline. Ventilators will need to be purchased, collected from the national stockpile, and repurposed from operating rooms, as non-essential surgeries will need to be cancelled.

Given the fact that testing turnaround is currently running up to 3 days at commercially available testing sites as well as some departments of health, which many hospitals need to rely on, PPE and needed resources may be wasted waiting for negative results. The expected case load in New York city will rise quickly in surges, causing excess bed capacity to evaporate quickly. Additionally, such a large adjustment of ICU capacity will also require large increases in the following categories: staffing; personal protective equipment (PPE), in particular masks; ventilators; and hopefully pharmaceuticals which may be effective in reducing viral shedding and transmission of COVID-19.

Specifically, certain drugs which may have an effect on both viral shedding and transmission or perhaps limiting disease spread, which are therefore critical to efforts to contain the virus, include hydroxychloroquine and azythromicin, which have preliminary positive results in a small study, as well as other medications, though a recent study shows less optimistic results for kaletra.

These may work best early in the course of illness requiring many doses to be on hand. These drugs should be acquired in their generic forms as rapidly as possible, given that medical interventions will act in this pandemic as the proof case for which drugs are most effective. Hospitals already with strained resources will need to compete with each other to place orders as data emerges in real time during this outbreak. Stockpiles and large purchasing orders can be too much of a risk for hospitals, but should be a risk shared with authorities. In short, only carefully designed clinical trials during the progression of active cases can prove the effectiveness of these drugs in real time, which makes it critical that stockpiles of all promising and relevant drugs exist so they can be rapidly administered and substituted as data changes.

Further, the most cost-effective way to rapidly decrease spread of COVID-19 in a highly urbanized environment remains the rapid quarantining of individuals. At this point in time, New York City has recommended people do not leave their homes for testing, only seeking care if needed medically. Impact of non-pharmaceutical interventions (NPIs) to reduce COVID19 mortality and healthcare demand. These may work best early in the course of illness requiring many doses to be on hand. These drugs should be acquired in their generic forms as rapidly as possible, given that medical interventions will act in this pandemic as the proof case for which drugs are most effective. Hospitals already with strained resources will need to compete with each other to place orders as data emerges in real time during this outbreak. Stockpiles and large purchasing orders can be too much of a risk for hospitals, but should be a risk shared with authorities. In short, only carefully designed clinical trials during the progression of active cases can prove the effectiveness of these drugs in real time, which makes it critical that stockpiles of all promising and relevant drugs exist so they can be rapidly administered and substituted as data changes.

Further, the most cost-effective way to rapidly decrease spread of COVID-19 in a highly urbanized environment remains the rapid quarantining of individuals. At this point in time, New York City has recommended people do not leave their homes for testing, only seeking care if needed medically. 8,9 More effective in a situation of runaway contagion is the immediate imposition of shelter-in-place rules. At the very least, New York City must immediately halt all congregation of groups, as contact between groups of individuals greatly exacerbates the spread of the disease and will lead to an exponentially larger surge of patients at a time when the medical system can least afford excess capacity requirements. This will require addressing the needs of the homeless to have adequate decongested housing and the need for quaranting facilities for nursing homes if they have cases. This also means addressing the needs of Rikers Island, which has just reported its first case, and other inmate facilities, where calls have been made to increase prisoner early releases to decongest the prisons, which will be a very difficult outbreak to control.

Implications

If immediate action is not taken, New York City will soon face a situation similar to that of Northern Italy, in which patient surges rapidly exceed local medical capacity, leading to a crisis and runaway, unnecessary mortality in case outcomes. The recommendations listed below, if enacted with utmost speed and vigor, can save thousands of lives and immeasurable levels of capital expenditure while keeping New York City medical outcomes within acceptable bounds, thus avoiding a major medical crisis with unconscionable ramifications.

Recommendations

  1. Immediately require a cessation of all social congregations in New York City.

2. Enact shelter-in-place requirements for all residents of New York in non-emergency situations, to impede the rapid communal spread currently occurring in the city. Essential activities including operation of groceries, workers essential to city function, and those who operate or maintain equipment critical to the function of the city should be exempted.

3. Creation of quarantine centers for nursing home patients.

4. Quarantine centers for homeless populations.

5. The release of non-violent offenders in the New York prison system, in specific those inmates suitable for release from the Riker’s Island Correctional Facility before community spread occurs in that facility en masse.

6. Boost ICU bed capacity to 50,000 units as soon as possible to avoid catastrophic runaway mortality.

7. Boost requisite staffing to meet bed capacity.

8. Ensure that all staff are provided with PPE for the duration of the outbreak. At the current moment this will require no less than 1 full set of PPE per staff member per day. New York had roughly 1.2 million healthcare workers as of 2018 and growing, so an estimated 1.5 million sets of PPE (masks, gowns, and gloves are highest priority) per day are required at minimum.

9. Boost ventilator capacity by 50,000 units. This will require immediate emergency funding and government orders from key providers at a maximum level (nationwide), as well as the allowance of open innovation for ventilator capacity from non-traditional sources.

10. The immediate boosting of stockpiles of generic pharmaceuticals with the potential to slow transmission and/or viral shedding, including but not limited to: hydrochloroquine, azythromycine.

11. Immediate disbursal of federal funding and resources to provide the abovementioned resources, with top priority given the potential effects of a large-scale runaway outbreak in New York City and the Eastern Seaboard.

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