It’s Not Too Early for Lessons Learned

In fact, maybe it’s a little late. In any case, it is definitely time to start thinking about the world’s regions/countries/entities respond to infectious diseases.

This should not be a political exercise. Instead we need to look at what works, what works but at too great a cost, and what does not work, and what does not work at too great a cost, and PLAN accordingly, from the information we have gained from an unprecedented amount of worldwide data.

We should have a plan for this type of agent (low virulence, easy spread, can impact vulnerable populations) and also for other infectious agents that may have different properties.

What have we learned about this specific virus?

1.It doesn’t usually bother young people at all

2.Serious complications, including death are extremely rare if you are under 50.

3.Most people will have no or mild symptoms, although the virus seems to possess the potential to make at least some people very ill.

4.The risk rises with age. The vast majority of deaths are in the over 75 years-old population.

So, our good/bad news is that most people are fine, or only mildly ill. This is basically a cold virus after all. That’s the good news. The bad news is that this leads to a large reservoir of infectious people walking around, spreading the virus—and older people can be at risk for much more complications and mortality if they catch it from them.

What should we do?

Here are two specific issues from this current viral outbreak.

First, we need to look at our approach to testing. We have done testing in this situation exactly the opposite from how it should be done. We have been testing people with severe symptoms. But why? We already know they are sick. There is no specific treatment for “coronavirus” that is any different from treating any other viral respiratory infection. If you are sick you can stay home for two weeks, or, if sick enough, go to the hospital for more intensive monitoring. FYI, any patient in the hospital with severe respiratory illness should be on certain precautions, including using PPE, so that also doesn’t change, and all hospitals these days follow “universal precautions” as well. Hospital workers can be pretty cavalier about following precautions in the usual run of business, but that’s a whole different issue.

Instead of testing the very sick, in this infection scenario we should be testing everyone else. Expensive? Sure, but shutting down a country’s economy is much, much more expensive.

Once you know who could be a potential spreader, you can isolate those people.

If testing everyone isn’t feasible, the experience of places like Singapore and Korea shows that aggressively tracking down contacts, or people that might be in contaminated areas and testing them is a good start.

Secondly, we need to protect the vulnerable members of the population, which for this virus is essentially those over 75. Nursing homes and hospitals need to step up and follow infectious precaution protocols, and may need go into lock down as far as visitors are concerned.  When this kind of virus is about people should not visit their older friends and relatives for two weeks after taking a plane flight (no holiday visits!) or attending a large concert or sporting event or taking a cruise.

But mostly we need a plan.

We need to do stratified risk analysis, in private, by trained clinicians who are experts at this work and used to thinking in these terms, before there is an emergency and people are being reactive, not proactive.

About risk. In the real world, the risk of any activity is never zero. Every time you step outside, you are risking being struck by lightning—lightning does not need a thunderstorm to happen. The risk is extremely low, but it’s not zero. Most of us would agree, though, that the risk is low enough that we do not need to worry excessively or stay inside, unless there is a thunderstorm happening right around us.

The point of designing a plan to contain an infectious disease outbreak is never to have no cases, or no deaths. The point is to “flatten the curve” and to minimize consequences to society, including both the economy and health.

The first steps have to involve weighing the effectiveness of each intervention. Did “stay at home” orders actually help? What about closing the schools? Was that actually effective in slowing spread? What about masks? Look at testing, of course. What helps and what is redundant? We don’t need the stress and economic effects from something that’s just “security theater,” designed to look like somethings being done, but which is actually ineffective. (Looking at you, TSA.)

Luckily, we do have this data in the United States. Each state has had a somewhat different timeline and interventions in place. By matching states similar in population distribution and characteristics we can see the effects of various interventions and evaluate their effectiveness.

In medicine, we call interventions that are backed by evidence that they actually work, “evidence based.”

The next steps should be about deciding when to implement each evidence based intervention.

There should be a step-wise plan in place, that can be used as soon as an infectious threat is identified, with specific parameters in place. These plans, of course, should be modified if necessary. However, they will provide a more evidenced based, targeted set of interventions, especially when compared having our interventions controlled by scared politicians.

How would this work? Well, for example, the guidelines could state that if such and such kind of agent reached so many cases, or showed such and such a rate of rise, then x and y will be put into place. If other criteria are met, then we add on a and b, and so on.

Remember, all these interventions should have evidence that they actually work, and consideration must be given to the overall risk/benefit ratio of each intervention. An intervention that kills or makes sick more people than it protects should not be used.

Right now, we cannot say what the specific interventions should be for each future infection problem. But we can say that the time to start working on this is now.