COVID-19: Battle Plan to Save Lives
“A Reconnaissance and Observation of COVID-19:What are the Tactics & Battle: What Do We Need to Do?”
Written By Vino Shelumiel Raj MD MBA , Fiona Ary MD , Susan Olet PhD and Stephanie Raj
Introduction: The Unforeseen Assassin
In December 2019, we had a new assassin invading our freedom. The virus SARS-COV2 causing COVID-19, (‘COrona VIrus Disease 2019’), is a new illness from the same family of Coronaviruses that caused the SARS (Severe Acute Respiratory Distress Syndrome) illness in East Asia, in 2004, and the MERS (Middle East Respiratory Syndrome) in 2013. News about its discovery started in Wuhan, China, in December 2019. (“Report of the WHO-China”, 2020).
The Destruction: Exponentially Growing
COVID-19 made known its destructive impact almost immediately. For many, life changed overnight. As of March 29, 2020, at exactly 10:08 PM central standard time (CST) The Johns Hopkins Coronavirus resource center reported that there are 722,289 cases of COVID-19 and 33,983 deaths worldwide (John Hopkins, 2020). Italy has seen the most significant spikes in the number of deaths 10,779 (John, Hopkins 2020).
The trillion-dollar question remains, why is it so challenging to stop COVID-19 in its tracks ? At the heart of the matter we are not able to determine those who are contagious (infectious) and those who are not. For example, Iceland has tested more citizens per capita (3.4%) than any other country in the world, finding that 50% of the infected are asymptomatic (“COVID-19 in Iceland” 2020). This reiterates that social distancing remains the best action that we can do to immediately decrease the transmission of the illness! Health care workers all over the world have not only understood this but have taken to social media to encourage social distancing by this widespread statement “We stay at work for you, please stay home for us”.
The following is some simple but eye opening non-mitigated math for the US. (If no action is taken; we are for this reason assuming a conservative growth rate of 1.27 based on WHO reputed research)
Growth rate per day to the power of(number of days) = multiplication factor to estimate # of infected.
1.27 (10) = 10.9 ( for 10 days)
As of march 28th US infected (only tested ) = 62,000
Est by April 4th =675,000
April 14th =7.3 Million
April 24th = 80 Million infected.
Mind you this is unmitigated and if we just go about our lives without any measures. This is a serious situation.
We rather prepare for the worse and have a better outcome than take it lightly and regret all those we will need to find room to bury
Associated History: What It Tell Us
As learnt from history, studies show that NPI (non-pharmaceutical interventions) have a crucial role in mitigating previous pandemics, and that the key to decrease deaths is social distancing (Hatchett, Mecher, & Lipsitch, 2007). In an article by JAMA researchers discuss how social distancing plays a crucial part in delaying the effect, peak attack, and can reduce the number of collective deaths (Markel, et al.2007). Yes, the idea of social distancing can be daunting and discouraging but taking these protective and proactive measures can buy valuable time for the production and research of vaccines, medications, and treatments. NPIs can help our health care systems and infrastructure by decreasing burdens and positive cases (Markel, et al.2007).
When the city authorities implemented preventive measures early, i.e., New York City in the year 1918, the death rates were 50% lower than in cities that did not act fast enough (Hatchett, Mecher, & Lipsitch, 2007) (Strochlic & Champine, 2020). Taking those cues, today, most states in the United States have executed multiple measures such as, mandated shelter in place and social distancing. There are numerous guidelines for social distancing, for workplaces, schools, homes, and commercial establishments (“What Every American”, 2020). The goal of these guidelines is to reduce the frequency of contact and increase the physical distance between persons, thereby reducing the risks of person-to-person transmission. Unfortunately, the news of college students congregating at beaches in Australia, Florida, California, and Texas, for spring break, demonstrated that social distancing is not a natural habit to adopt, for most people, even though this measure can save multiple lives.
Reconnaissance, observation and data preparation of the battlefield
The Enemy’s Tactics and Operations
According to the cases, 80 % of the infected exhibit a mild to moderate presentation of the common symptoms:
· fever
· cough
· shortness of breath
· fatigue (Auwaerter, 2020).
Along with these symptoms there is: stable heart rate, respiratory rate, blood oxygen saturation
These mild cases do not need hospitalization. However, they would require hospitalization or admission to an intensive care unit if the following develops:
· acute respiratory distress syndrome
· severe pneumonia
From initial data, the vulnerable groups are:
- Immuno-suppressed individuals
2. People with co-morbidities such as: Cancer, hypertension , respiratory system disease and cardiovascular disease (Yang, et al., 2020).
3. Elderly
Additionally, in China the case fatality rate for people aged 60 years and above is 26.4%, as noted in the figure below. The CDC COVID-19 Response Team reported that adults of any age with COVID-19 could be affected severely (2020). Death in younger age groups is possible, but rare, as evidenced by the reports of the two teenagers’ death associated with COVID-19 in Louisiana and California. It is unclear for now, but the experts think the difference in data between China, the US and Europe may be explained by:
· eating habits
· obesity rates are higher
· young adults are reluctant to practice social distancing.
Field Assessment Comparisons
Italy: Lombardy Vs. Veneto
After 11 deaths and 309 positive cases of COVID-19, Italy was still declared safer than other countries. Two weeks later, the Italians had to cremate their dead because there were too many bodies to bury. Why did this happen? People did not perceive the crisis to be severe and kept their usual activities, socializing, and gathering.
Let’s compare two cities in Italy, Lombardy and Veneto and how their approach to COVID-19 and social distancing made a difference. Both reported the country’s first cases on the same day. Their response, however, differed:
Veneto issued the following:
· Testing (multiple rounds of testing were done, even for those asymptomatic)
· Isolation (those that were positive were isolated)
On the contrary, Lombardy lagged in testing those who were asymptomatic. Why is testing for asymptomatic important and how could Lombardy have benefited? Nearly a month later, Lombardy has reported far more cases than Veneto — which points to the benefit of aggressive testing and isolation as a successful response. Looking at Lombardy’s Patient One, we can see how testing is vital to staying on top of this virus. Patient One was just a local Italian with no history of travel overseas and no close contact with positive cases for COVID-19. A month before the appearance of his symptoms, he attended dinners, played soccer, and ran with a team. The patient was asymptomatic, and during this month, he was a “super spreader”. He unknowingly spread the virus to many people. Which left Lombardy’s hospitals overwhelmed by the numbers of sick needing intensive care(Saglietto, A., D’Ascenzo, F., Zoccai, B.G., Ferrari, D, M, G. (2020). During this short time, one of the world’s best health care system collapsed due to their limited capacity of intensive care unit departments to treat their sick (Saglietto et al, 2020).
South Korea:
In South Korea it was Patient #31, who was the “super spreader.” She attended a megachurch service in Daegu and infected many before realizing she was contagious. Yet South Korea has gone down to number 12, on the world chart, with 9,583 confirmed cases. South Korea managed to do this through severe techniques, that have proven to be lifesaving. South Korea did the following:
· Testing (compulsory testing, even those who were asymptomatic)
· Isolation (mandatory isolation, even those who exhibited only mild symptoms)
· Government surveillance via credit cards, cell phones and GPS tracking to track travel routes and locations. This tracking enabled the government to quarantine the responsible individuals and those they had contact with.
(Lucas, 2020).
The US in comparison, to South Korea, has been discouraging testing for asymptomatic individuals, due to the lack of tests and materials. Also, when tests that are performed, results often take days. These strict, mandatory actions performed by South Korea are actions that wouldn’t sit well with the US population, a country that is rooted deep in individual freedom. So that leaves the question, what can the US do to slow COVID-19?
The US:
The US people haven’t realized it, but ICU beds in the United States is a limited resource. The US current health care system is vulnerable to pandemics, such as COVID-19. The US health care system has 95,000 ICU beds. However, on any given day, these beds will be 95% occupied by other patients with various needs. Louisianans, with their love of parties, i.e., Mardi Gras, responded poorly to social distancing, causing the state to have the fastest growth of COVID-19 cases in the world, surpassing Italy’s trajectory! The Governor of Louisiana, John Bel Edwards, has already warned President Donald Trump that Louisiana’s health system will run out of beds in two weeks if people still disregard the official warnings seriously. This health crisis will wipe out the state’s entire healthcare system in a matter of weeks or days. The long duration of intensive care needed to treat severe COVID-19 illness (11- 21 days) will cause inadequacy to treat other incoming COVID-19 patients. Secondary casualties, too, will occur because of hospital overflow. Patients with heart disease, stroke, cancer, accidents, childbirth, to mention but a few, simply will not get adequate medical care when the hospitals are overwhelmed.
Defense Strategies: Assets, Battle Gear, and Tactics
With such devastating numbers that are exponentially rising, how we the “people” respond to authorities and NPIs in place will not only define the rate of infection, but the final fatalities caused by this virus.
NPIs
On the Eastern seaboard, New Rochelle in Westchester county, New York, also showed us that early social distancing makes a difference. When the city of New Rochelle had a cluster of COVID-19 cases, their officials quickly set up a one-mile “containment zone” and set up a drive-thru coronavirus testing site. They ordered social distancing by closing religious events, large gatherings and called in the National Guard to help coordinate delivering meals to those in quarantine (Levenson, 2020). These measures worked. The current data shows that the new cases in New Rochelle are declining vs. other cities in Westchester county (Levenson, 2020). Population density certainly did not do New York City any favors. It is challenging to stay physically 6 feet away from another person in an overcrowded street or subway car. Contact rates tend to increase with population density, accelerating virus and becoming a factor why New York City currently has the highest toll of death in the US due to COVID-19 transmission (Hao,H., Nigmatulina,K., Eckhoff,P.(2013).
The Tactical Pursuit: Social Distancing, Our Main Arsenal
Social distancing is not about an individual. The Chinese understood early on that slowing the spread of the virus is not about them but for their fellow man. They have big printed red banners hung in public areas and near residential housing areas, with reminders to do social distancing. The sentences on these banners directly translated as “Visiting kills each other, and congregating is suicide” “Sleeping at home is better than sleeping in the ICU.”
There are also other issues to consider why it is imperative to do social distancing. While the pharmaceutical and research industry are working furiously to develop a vaccine via clinical trials, there are reports that this novel virus has mutations of different strains. It is unclear if these mutations are significant or a person can be re-infected (Salo, 2020). This uncertainty leaves the question of whether a vaccine is sufficient to combat COVID-19. We currently do not know enough to answer this question. The experts are also unclear about this virus’s sequential testing information. A negative test today may not mean you are not infective tomorrow and let us not forget that there is a dire shortage of test kits for COVID-19 all over the world.
Battle Gear: What Does It Look Like?
Simple Key Tip: Maintain 6 feet away from anybody!
1. Avoid gathering
2. Do not assume that someone is not infectious if that person has no symptoms. Remember Italy’s super spreader, Patient One!
3. Avoid dine-in restaurants, sit-down cafes, bars, libraries, museums, movie theaters, trampoline parks, and any other non-essential indoor public location.
4. Do wash your hands and disinfect high touch surfaces.
5. Do not assume that you, your significant other, or your family members are not infected. Try to keep your distance as far as possible from your loved ones if you live in the same dwelling.
6. Do not visit vulnerable groups such as the elderly or the immuno-suppressed.
7. Use other means to interact remotely
8. Do not go to a health care facility unless necessary; there is a higher risk of contact with the infected.
9. Avoid barbers, salons, spas, or other such high-touch non-essential services.
10. No children play dates that can cause physical contact with other children.
11. Take proper precautions when getting deliveries or take-out and using drive-thru; eating food that has not been prepared or transported correctly can put you at risk of weakening your immune system.
12. If you are a health care worker, and have a high risk of infection, consider living in different living quarters to minimize transmission to your loved ones.
13. In public facilities, do put measurements and barriers to help others keep their distance from each other
(Lee, 2020).
Review of Operations:
The main goals achieved by mitigation are, minimizing morbidity and associated mortality, avoiding an epidemic peak that overwhelms health-care services, and flattening the epidemic curve while waiting for vaccine development, manufacture, and antiviral drug therapies.
However, it is essential to remind everyone that mitigation and social distancing is not emotional distancing. The World Health Organization (WHO) is currently discouraging the use of the phrase ‘social distancing,’ and the organization urges us to use the phrase ‘physical distancing’ instead (Tangermann, 2020).This definition provides a clear understanding that the COVID-19 pandemic is not about breaking social contacts with your family and friends but about keeping a physical distance to ensure the disease does not spread. We will not be able to get through this massive challenge without emotional support. However, we must act now, right this minute. STAY HOME AND PRACTICE PHYSICAL DISTANCING. We can make a difference together!
If there is one thing that you walk away with, from this article, let it be this:
Never has the call of individual behavior been more crucial to the change of history-
Rather than the dependency on government actions, personal and social decisions remain the crucial strategy in the combat of this pandemic, therefore the challenge to save lives is up to us.
Co- authors by Fiona Ary , Susan Olet PhD & Stephanie Raj
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