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A thread on why I am not panicking about #Coronavirus #COVID-19.
In 2003, the world experienced an outbreak of SARS (Severe Acute Respiratory Syndrome). I was in med school. Initially, the illness seemed to be linked with travel to China, but the Chinese government was not saying anything about it.
The cause of SARS was completely unknown, and it was five months between the illness first appearing and the World Health Organization (WHO) becoming significantly involved, alerting public health authorities around the world.
It took months to identify that the cause SARS was likely a new Coronavirus. It took months more to develop a lab test to confirm the illness. That lab test was slow (blood test for immune system response, which only identified illness weeks after it began).
The situation with the current Coronavirus (COVID-19) outbreak is much different. China's handling has not been perfect, but they did inform the World Health Organization much earlier – almost as soon as they had enough information to be able to do so.
The virus was identified within a couple of weeks, and lab tests were available almost immediately. The lab tests that were quickly developed for COVID-19 use PCR technology, which only needs a tiny fragment of DNA to identify a case. PCR testing is generally very accurate.
[Side note: the Chinese government built a world class lab facility a few years ago right in the city of Wuhan, where the COVID-19 outbreak began – exactly to help combat this sort of outbreak.]
More importantly, PCR testing can be used early in the course of illness, using only a throat swab. This means we know definitively whether someone is infected within days of the illness beginning, not weeks.
In 2003, cases of SARS began to mount, and travel advisories were issued. Unfortunately, health care workers seemed to bear the brunt of the outbreak in some places. This was largely related to a lack of appropriate protocols at that time in history.
Up to that point, the risk to healthcare workers in developed countries of acquiring serious and fatal infections at work had been relatively low for decades. Post-World War II, we have generally had better nutrition and housing conditions.
That means we have better general health and less vulnerability to serious infections. Vaccines also have dramatically reduced or eliminated many illnesses since WWII that could previously make young, healthy people sick and die. #VaccinesSaveLives
After decades of lower risk, healthcare workers and institutions were not attuned to handling this sort of patient. 17 years ago with SARS, there were a number of “super-spreading” incidents – a term that masks the fact that these were preventable system failures.
In these super-spreading SARS incidents in 2003, high-risk procedures such as bronchoscopy were performed in crowded emergency rooms (NB: this is NOT DONE ANYMORE). Bronchoscopy is the insertion of a scope (a camera on the end of a probe) into the lungs.
Bronchoscopy can generate vigorous coughing of the type that would propel the virus further than the usual cough. This procedure is now done only in controlled conditions.
Coronavirus is a large virus that lives on droplets. Under normal circumstances, coughs and sneezes only propel it one metre, mayyyyybe two. Maybe. It is not an “airborne” virus like measles or chicken pox, so it cannot float through the air on tiny dust particles.
As @alexsummers4 says, "this is a HUGE virus" (it’s physically large, compared to other viruses). When it is coughed or sneezed out, it really wants to hit the floor.
But with a high-risk procedure like bronchoscopy, a vigorous cough response can propel a droplet much further than the one metre distance of a cough or sneeze. We now know that such procedures need to be done in confined rooms, not crowded ER’s.
Healthcare providers performing and attending procedures like bronchoscopy now to wear appropriate personal protective equipment (masks, face shields, gowns, gloves, etc.).
We also now have many more negative-pressure isolation rooms that add an even greater level of protection. These rooms suck air in, filter it, and then vent it out safely. Even airborne diseases like measles cannot travel beyond the walls of a negative-pressure isolation room.
We also have protocols now for every healthcare facility. Universal Precautions (e.g. frequent handwashing and/or gloves) are known and practiced by every healthcare provider. You may have also noticed the signs and masks when you go to a hospital.
If you have a cough, you are asked to immediately as you enter a hospital to put on a mask. If you have a cough plus a fever, you are separated from other patients, and healthcare providers use enhanced precautions to ensure they are not infected.
[Side note: nobody’s perfect, and you are part of the team. If you see a healthcare provider forgetting to wash hands, or identify someone sitting in the waiting room next to you who seems to present a serious risk to your health, please don’t hesitate to speak up.]
Another major change is improvements in the legal authority, profile, and in many cases resource levels, available to local public health agencies. Legislation has been strengthened to allow medical officers of health to order any appropriate steps to contain a serious illness.
In many jurisdictions, resource levels have been enhanced since 2003 so that we have more public health nurses, inspectors, epidemiologists, and medical officers of health to help contain issues such as Coronavirus.
[Side note: public health resources have been cut in some jurisdictions. Let's hope that this does not result in more spread of infectious such as COVID-19.]
Isolation procedures have been enhanced. For example, the vast majority of cases of COVID-19 we are seeing in Canada are being isolated at home, rather than in a healthcare setting. This means much less interaction with others, and much less potential spread.
Virtually everyone working in public health right now across Canada grew up and/or has worked for 17 years in the post-SARS era. We think about this all the time. We plan for it. We train for it. We hope it never comes, but when it does, we are ready.
National and international communication/coordination procedures are in place. Canada now has @PHAC_GC, and Ontario has @PublicHealthON. These agencies are tasked with monitoring, preparing for, and coordinating responses to threats like COVID-19, and also superb lab systems.
@PHAC_GC @PublicHealthON Locally, we have for many years had regular contact with healthcare, municipalities, and other key partners in addressing outbreaks like this. We have developed a distribution list of all primary care providers (e.g. family docs) in the area.
@PHAC_GC @PublicHealthON When issues like COVID-19 occur, @MLHealthUnit routinely notifies over 1000 healthcare leaders across #ldnont and Middlesex. If you are a primary care provider or healthcare facility head in this area and are not on our distribution list, please email health@mlhu.on.ca
@PHAC_GC @PublicHealthON @MLHealthUnit Hospitals here have been aware of COVID-19 since it was first announced (I emailed their CEO’s Jan 3), and they have been taking this seriously, and taking concrete steps to ensure preparedness since then. Primary care providers were notified Jan 7, and updated as issues evolve.
@PHAC_GC @PublicHealthON @MLHealthUnit We are also seeing a huge amount of cooperation and proactive risk reduction by affected patients. People are willingly complying with isolation. In the London case we reported recently, the individual was self-isolating even before she became ill!
@PHAC_GC @PublicHealthON @MLHealthUnit It’s also important to note that COVID-19 is a much less severe infection than SARS. In China, the case-fatality rate seems to be about 3%, compared with 11% with SARS. Outside of China, it appears to be more like 1-2%. So almost 10 times less fatal.
@PHAC_GC @PublicHealthON @MLHealthUnit The one thing we don’t know is whether COVID being less serious/fatal means that it might be more easily spread. A walking patient can come in contact with more people than one who is sick in bed. The statistic we use to measure this is R0, the basic reproductive number.
@PHAC_GC @PublicHealthON @MLHealthUnit R0 is the number of people to whom an average case spreads the infection in a “naive” population (i.e. a population that has never experienced this virus before). If R0 is great than 1, that means that each case of infection will cause more than one subsequent infection.
@PHAC_GC @PublicHealthON @MLHealthUnit So if R0 is greater than one, an infection will spread (outbreak). If R0 is less than 1, it won’t. The job of public health is to intervene when R0 is greater than one, and put measures in place to get R below 1 (e.g. isolation of cases, or vaccines when available).
@PHAC_GC @PublicHealthON @MLHealthUnit Initial estimates of R0 for SARS were in the range of 3 (each case produces 3 additional cases). Once public health measures were put in place (probably with the health of better weather in Spring), they got the reproductive number down to about 0.4, and the outbreak ended.
@PHAC_GC @PublicHealthON @MLHealthUnit Initial estimates for R0 for COVID-19 are the same – about 3. In Canada, where appropriate public health measures have been in place since before the virus even arrived, the reproductive number is below 1 already.
@PHAC_GC @PublicHealthON @MLHealthUnit We have had 13 cases of COVID-19 in Canada, and only four were from spread within Canada. All of these were in close household contacts (e.g. the husband and wife case announced today). There is no sustained person-to-person spread in Canada at this point.
@PHAC_GC @PublicHealthON @MLHealthUnit To recap, compared with SARS, the COVID-19 situation is better because:
- Government in China communicating early and frequently
- Virus identified almost immediately
- Better lab test available much sooner in the outbreak
- Better awareness among healthcare providers and leaders
@PHAC_GC @PublicHealthON @MLHealthUnit -Better understanding of virus spread in healthcare facilities
-Better screening protocols when entering hospital
-Better protocols for invasive procedures like bronchoscopy
-Improved international coordination
-Improved national leadership and labs
@PHAC_GC @PublicHealthON @MLHealthUnit -Improved provincial leadership and labs
-Strong local coordination
-Strong awareness and cooperation from patients
-How easily the virus spreads is unknown, likely similar to SARS
-There is no sustained person-to-person transmission in Canada at this point.
@PHAC_GC @PublicHealthON @MLHealthUnit Please be clear, this is a big deal. It’s just that it’s a big deal that we have spent many years preparing for. There will be more cases. There will be mistakes made. There may even be deaths in Canada. But this will not devastate our health or economy as it has in China.
@PHAC_GC @PublicHealthON @MLHealthUnit The biggest risk with COVID-19 is panicking. Supply chains are at risk in China not because of the virus, but because entire cities of millions of people have been cut off by the government. This intervention is not justified by evidence, and is proving ineffective.
@PHAC_GC @PublicHealthON @MLHealthUnit We need to get back to reasonable responses. Yes, this is a new coronavirus, but we know a lot about Coronaviruses (not just SARS, there have been others). We have tried and true measures that will work to contain this if we let them.
@PHAC_GC @PublicHealthON @MLHealthUnit Sure, have a three-day supply of food on hand in your home. But not because of COVID-19. Do it because it’s a long-standing emergency preparedness recommendation for any emergency. In this country, ice storms are much more likely to cause supply chain disruptions. /END
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