On March 7, New York governor Andrew Cuomo declared a “state of emergency” as the number of cases of Covid-19, the disease caused by the new coronavirus SARS-CoV-2, reached 89 statewide. So far, no New Yorkers have died. Over 4,000 people who may have been exposed have been asked to self-quarantine. Many are medical personnel who are now no longer available to treat patients for Covid-19 and other problems. Earlier in the week, an Uber driver walked into a Queens hospital complaining of flu-like symptoms; he later tested positive, and now 40 doctors, nurses, and other hospital workers are self-quarantined, since they may have been exposed to coronavirus. The New York experience to date suggests that the disruptions this new virus causes—particularly to the availability of medical care, for any condition—may be more dangerous than the illness that it causes.
SARS-CoV-2 is highly transmissible, spreading easily from person to person. Nearly all the New York cases have been in Westchester County and New York City, and most are related to exposure to one infected lawyer who travelled between his New Rochelle home and his office in midtown Manhattan. However, Covid-19 is usually not a severe disease. Over 80 percent of infections are asymptomatic or cause mild, self-limiting illness. A recent Chinese study of hospitalized, laboratory-confirmed Covid-19 patients reported a case fatality rate of 1.4 percent—but even this figure is likely high, since hospitalized patients are the most severe cases. Tens or possibly hundreds of thousands of milder, non-lethal Covid-19 cases have undoubtedly gone unreported. South Korea, which has the world’s most extensive testing system and a more accurate count of the total number of cases, reports a case fatality rate of 0.7 percent. And even this rate is likely too high, since only a small fraction of the population has been tested, and many asymptomatic and mild Korean cases are likely going unreported. The people most at risk of severe illness or death are the elderly and people with underlying medical conditions, such as lung and heart disease and diabetes. These are the people most in need of protection.
Still, Covid-19 can be highly disruptive. Its rapid spread overwhelmed Chinese hospitals. Hundreds of medical personnel were infected. Lack of space and fear of exposing medical staff to the highly infectious virus led many hospitals to turn away new patients, even those in need of urgent care for conditions other than Covid-19. Ensuring that sick people get appropriate care, while preventing the spread of the infection, is the key problem facing the U.S. now. It’s particularly acute in hospital emergency rooms and physician’s offices, where Covid-19 patients can infect medical personnel and other patients, often elderly or with other medical problems, who are waiting to be seen.
Several common-sense solutions come to mind. Government and medical leaders should inform the population through multiple means that mild cold symptoms like a low-grade fever or cough do not warrant leaving home to seek medical attention. Symptomatic elderly persons and those with underlying medical conditions that make them more vulnerable to severe complications should be instructed to stay at home and call for medical assistance, and local public-health personnel should be available to screen them in their homes.
Provisions must be made to protect the public and medical personnel when Covid-19 patients seek medical care. People who become severely ill with high fevers, shortness of breath, chest pain, and illness-related confusion or delirium need emergency care. Screeners who find ill patients in need of immediate attention should alert ambulance crews and ER personnel to wear protective equipment and bypass the emergency room, where other, uninfected patients are waiting. Other patients will come to the hospital on their own. Emergency rooms should create triage facilities to screen out potential Covid-19 cases before they reach unprotected patients in the waiting room or unprotected medical personnel.
Finally, separate facilities that can physically isolate Covid-19 patients from other patients must be made available. Should large numbers of people become infected, it could overwhelm the capacity of hospitals to sequester patients. Every hospital should be required to have contingency plans to make more isolation beds available.
Now that the manufacturing problems that compromised the reliability of the Covid-19 diagnostic test kits have been resolved, the CDC and FDA have ramped up production, utilizing private manufacturers. The FDA reports that more than 1 million test kits have been shipped nationwide to public and private health labs, and millions more will soon be available. In addition, the FDA has facilitated the development of other diagnostic tests through the Emergency Use Authorization process. The availability of rapid diagnostic tests, combined with the common-sense measures outlined above, should facilitate the identification and isolation of Covid-19 cases, curtail the spread of the virus, protect those most likely to suffer severe Covid-19 illness, and protect the medical personnel at the front lines of our health-care system.
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