Mass Testing for COVID – 19

Wall Street Journal Article 4/1/2020

Controversy abounds over this topic. Smaller countries that subscribed to this process early on seemed to have gained control of of new cases as they isolated patients with positive tests but no symptoms (around 50% of those testing positive. Keeping these asymptomatic patients quarantined controlled the increase in new cases. South Korea was successful in isolating contacts by tracking cell phone contacts in those that tested positive.

Now the virus is too far spread to think that testing all except perhaps in high density areas of infection would help control the spread. The prioritization of testing outlined in the CDC guidelines may be a reasonable approach at this late stage.

The blame game of too little testing too late reminds me of the argument during the healthcare reform debate. It is not reasonable to compare countries the size of a single small state in the US to the US response and control process. Geographic disparities in demographics preclude uniform approaches used in smaller countries.

What I find fascinating about a week ago is that when you overlay the maps of SARS-COV-2 infection (test positive for COVID-19) with the maps of major US International airports they are nearly identical. The FAA may find themselves playing critical role in future pandemics. Ease of international travel has always been a major concern in epidemiology.

Pandemics of old were controlled with local attrition. Cohorting the diseased was a natural process as the diseased were almost always relegated to the ghettos. The destitute with poor hygeine, poor nutrition, and no way out.

Economic prosperity paradoxically has abolished the “COVID-19 Gini coefficient” with respect to those who are at risk for contracting the disease. Socialized medicine has exacerbated the limitations in delivery of intensive medical needs. Social media has woefully degraded the tolerance of isolation and quarantine. Global supply chains and outsourcing of goods have catastrophically impacted not only the economic health of our country but also has restricted our ability to respond and protect those that need it most in their efforts not only to manage the critically ill but also to be protected from the virus itself.

Perhaps mass testing should be shifted to areas of low viral penetration to protect these areas by identifying asymptomatic infected individuals and appropriately quarantining them and the people they have exposed. Small pockets of this country remain relatively disease free. The virus stays airborne for about 3 meters. In many cases this may turn out to be across county lines. The areas of the healthy may lead the recovery by staying virus free.

The current paradigm of mass testing of the hospitalized and those in high density areas may need to shift to the above outlined approach. In the highly penetrated areas assuming the patient with symptoms has COVID-19 , identifying their contacts and treating both symptomatic and asymptomatic with medicine having a risk benefit ratio in favor of treatment could go a long way to limiting hospitalizations, maintaining quarantine, limiting exposure of healthcare personnel, and potentially slowing the spread.

Grants, grants everywhere!

As I read through legislation(s) recently passed in an effort to keep the economy stable, support small business, and in the most recent legislation support health care entities hit hard by COVID-19, I am struck by the focus on the here and now without regard to the reality that this represents a single pandemic and does very little towards addressing future pandemics which unfortunately are now the “norm” for forecasters of healthcare and economics.

The legislation, while providing millions, even billions of dollars for grant purposes, through several governmental facilities, outlines almost nothing regarding planning and implementation of programs that will facilitate the handling of future pandemics as they occur.

After addressing the SBA loan programs; most of the legislation addresses how the federal government can and will expand testing availability across the country. Monies for the “repurposing” of facilities, development of testing, treatment of a novel disease, vaccination for SARS COV-19, and staffing of developed programs is proposed through numerous grant opportunities.

No grant funding is ear-marked for “what if” future events. Today’s news included stories of struggling healthcare entities closing or threatening closure in many states. Additionally, fallout was reported regarding the state of Connecticut opting to relocate patients as they recover from COVID-19. Timely. Yesterday, while perusing the latest legislation (25 pages of strike through and replacement from the original PPP legislation), I took time to create a preliminary list of grants that could be written to address some of the major stumbling blocks  encountered in delivery of care during this pandemic. I have included them below. These are just a start. Hopefully, someone out there is thinking about the next time. The repercussions of a failure to plan for future pandemics will result in a repeated catastrophic impact. Clearly, we cannot think of everything; but there is a foundation, an informed infrastructure development program that can be created based on recent experience.

One of the great parts of being a citizen of this widely disparate country is we have room. We have demographics that make rule difficult while at the same time offering opportunities to compartmentalize, to stratify risks, to “dance” in response to challenges. Highly populated areas are affected in different ways then those with lower population densities. Ethnic differences impact economies and spread of disease while simultaneously providing answers and challenges. Religious preferences provide risks in community yet the solitary picture of the Pope conducting Easter mass resonates in my memory as an illustration of the impact leaders of the faithful have had in controlling the spread of this disease. Lean business policy decisions have proven disastrous in supply chain for critical needs in healthcare as well as other parts of the economy.

As a healthcare professional the grant ideas presented below are focused on that segment of our response.

Virtual Critical/Specialty care

  • Create minimum IT support/ equipment structure to allow shipping of self-contained units to homes/offices of qualified providers (MDS, ACPs, CCRN, Anesthesia, ER, Infectious disease) Virtual Critical /Specialty Care Pods
  • Training the trainers
  • Training IT support
  • Internet Access
  • Credentialling providers
  • Create and maintain an active rural health infrastructure/model for Virtual ICU manning similar to TeleStroke.

Home Care Specialists

  • Programs for training Home Health Care personnel to respond to new challenges for testing, treating, etc in homes.
  • Surveillance models
  • IT infrastructure to limit exposures – blue tooth vital signs, etc.
  • Development of triage models
  • Defining participants and readiness

Regional Emergency Health Care Reserve Facilities

  • For creating prototype process to repurpose and retrofit abandoned hospitals and/or put program in place to support currently struggling systems (rural> urban?) that can be rapidly recruited and respond and act as reserve testing centers (labs), recovery centers, supplemental critical care beds, domiciles to create social distancing options for nursing homes in time of epidemics,  etc.
    • The role of government in this case is to offer the private sector support by creating reserve facilities status in stressed urban and rural facilities affecting their survival in providing community needs during normal demand.  Imagine the contagion.
  • Creation and manning of transport programs (Aerovac, ambulance , buses, trains)
  • Manning of security services to maintain readiness of facilities
  • Development of program to enlist National Guard (or similar qualified services) to train security services, etc charged with maintaining facility security and readiness of facilities when not in use.
  • Create large tracts of land in moderate environs with infrastructure (plumbing, cafeteria, etc) in place to support temporary villages for infected and mildly symptomatic patients

NIOSH expanded services to test and approve PPE ( NIOSH approved )– todays mask is tomorrows double glove, ear plug, nose clips, etc.

  • Approval process for PPE
  • Allocation/reallocation of materials

Risk Stratification programs:

  • Minimal to high risk for contracting disease (exposure scenarios)
  • Minimal to high risk for exposing others to disease (exposure scenarios)
  • Minimal to high risk for severity of symptoms/disease manifestations (comorbidity scenarios)

Risk Mitigation Programs:

  • Voluntary tracking programs
  • Community testing
  • Immunity testing
  • Education- just the facts, take media/politics out of picture

These are just thoughts generated in an hour or so. There is a lot of money floated for grant purposes. Perhaps some of these ideas or others will catch someone’s attention and allow redirection of some funds to addressing preparing for a very different future.

References:

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https://www.wsj.com/articles/as-coronavirus-cases-climbed-private-equity-owned-hospital-faced-closure-11587893400?shareToken=st96dbee3f6279400b8de95fbfbe1b41f0

https://www.wsj.com/articles/connecticut-plans-to-relocate-patients-recovering-from-coronavirus-and-the-first-arrive-in-a-small-town-11587916839?mod=lead_feature_below_a_pos1

Social Distancing-A luxury

Very interesting to see that social distancing still favors the wealthy. Going to catch some heat for this post. Reading the Wall Street Journal article on prior generations experiencing pandemics as a routine part of life leaving them better prepared (less anxiety, fear, and panic) than we are now. Discussion about The Colera epidemic effecting New York in 1870 where one option was to “run like hell”. I found the Discussion regarding the “well filled stage coach” leaving town and distancing themselves from the epidemic. The vast majority of Cholera- related deaths Involved the indigent Irish population in the slums of New York.
Now We find ourselves dealing with the pandemic of COVID-19. Containing the spread of disease necessitates social distancing. Unfortunately, decisions by governmental authorities of past and present regarding how we deal with the “ impoverished “ population limits the effective implementation of social distancing. . Those that are more dependent on government are the ones that are least likely to be able to comply with social distancing. The school lunch programs, the often crowded low income housing, and the dumbing down of our educational process inadvertently created barriers to effective pandemic management.
I recently read an article about safety net programs “lifting” an entire demographic out of poverty. In reality, these programs trap that same demographic. Creation of a population dependent on government programs does nothing except to aleviate the social and moral responsibilities of families to their loved ones ( the elderly population), create a road for irresponsible family planning, and hinder the development of the human capital desperately needed for our future, among others.

So now a pandemic will be prolonged, more people will die, economic conditions will deteriorate more rapidly and recover more slowly, and the very population government is meant to protect ( in this case, the elderly) will suffer the most.

Perhaps, we will learn, less reliance on the government in our lives leaves us better prepared to respond to societal crises.

More or less government involvement in healthcare during the COVID-19 Pandemic?

Wall Street Journal Articles today reviewed the plans by Democrats to use the pandemic to argue for increased government involvement in healthcare. Interestingly, another article discussed the reasons for Italy’s systematic failure in addressing the beds/population statistics which have been defined by the government. The UK has opted to adopt a delayed approach and plans to expend health care dollars in treatment rather than containment. Now as all recognize the spread of the virus as out of control in the European Union as well as in the UK a travel ban has been appropriately expanded to include the UK and Ireland.

Government involvement in the delivery of care is likely to bog down with inefficiencies and bureaucratic quagmires that will prove to exacerbate the pandemic. Coordination of response, education of the public, and support for those economically impacted by the pandemic are all appropriate governmental actions.