Thomas M. File, Jr., MD: COVID-19 Requires a Unified Approach

As our readers are aware, a novel coronavirus was identified in China in late 2019. As the virus has emerged over the past few months it has since been diagnosed among travelers from the central China city of Wuhan to several countries including the United States. This infection has now been designated as COVID-19 and the associated virus has been labeled SARS-CoV2.

I suspect many readers have been on the front lines of this outbreak in various respects. Many infectious disease clinicians have been working to assist in the preparations of our facilities for possible identification, isolation and management of cases. Information is emerging rapidly, but there are still many aspects of this infection that are not known: how to estimate accurate lethality or morbidity; specifics on how the virus spreads; the effectiveness of our current control measures; whether a vaccine will be developed; and if antivirals such as remdesivir can produce any benefit.

Thomas M File Jr., MD, MSc, MACP, FIDSA, FCCP

Will COVID-19 “go away” as the weather warms into spring and summer like other seasonal respiratory infections? Perhaps, but we must remember that during the 2009 H1N1 influenza outbreak, activity continued well into the summer of 2010.

We are currently in the “learning phase” for COVID-19 and information is rapidly changing. So, what is current now may change by the time this article is published.

For me, this is somewhat a déjà vu time as I was in China in 2003 at the time of the notification of sudden acute respiratory syndrome (SARS) and I recall the response to that outbreak of a “novel coronavirus.”

At the time of writing, there have been > 90,000 cases identified in China and more than 60 other countries. However, I suspect this is an underestimate and that there are likely many cases that have not been identified due to mild symptoms or even possible subclinical cases. Of interest, as the case count increases the mortality rate has remained stable at about 2-3% (but also a likely overestimate since the denominator is unclear). Over the past few days, the number of new cases reported outside of China has exceeded the number of new cases reported in China.

From the available information, transmission of SARS-CoV2 is more efficient than with other recent novel coronaviruses (SARS and Middle East respiratory syndrome [MERS]) and also appears to be more efficient than seasonal influenza. The R0 (‘R naught’; number of cases spread from an infected case) for COVID-19 is estimated at 2-3, whereas seasonal influenza at 1-1.3. Although the primary transmission of SARS-CoV-2 seems to be from symptomatic patients, there are reports of transmission from asymptomatic patients.

The full clinical spectrum of COVID-19 has yet to be clarified. In an initial report of the > 70,000 cases from China, most confirmed cases (80.9%) were considered mild. The article also reported that the overall case fatality rate was 2.3%. Of importance 1716 health workers had become infected and 5 died (0.3%).

A secondary effect of the outbreak has been the emergence of hospital-acquired infections (HAI), particularly in patients who required mechanical ventilation. In a report of 52 critically ill patients, 13.5 % acquired an HAI, some of which were linked to antimicrobial resistant pathogens, including 1 case of Carbapenem-Resistant Enterobacteriaceae.

Aggressive, unprecedented travel restrictions and quarantine have been implemented by many countries, including the United States, with the goal of reducing the number of COVID-19 cases into the country. This appears to have been successful in “slowing” the emergence of COVID-19 in the United States, but at the time of this writing there have been several cases of apparent community spread (not related to travel or known exposure to a confirmed case).

Last week, the US Centers for Disease Control and Prevention (CDC) updated their definitions of “person under investigation” (PUI) to include persons with respiratory symptoms who have recently traveled from Italy, Japan, South Korea and Iran. This definition may change as other countries seem to be experiencing sustained community transmission.

In addition, the new PUI definition includes patients with severe respiratory infection for whom there is no known etiology. As this is not uncommon in our intensive care units, this will significantly increase the number of potential patients of concern and increase our need for diagnostic assessments.

With this change in definition and with increasing testing capability by local health departments, we have to anticipate there will be additional cases and soon our public health response may have to change to one of mitigation. Until there is a vaccine or an effective antiviral agent available, this may mean implementing various types of social distancing and stressing common health recommendations. Individuals are already advised to avoid sick persons, wash their hands, stay home if sick, and practice respiratory etiquette. It may also be recommended to avoid shaking hands, (we can elbow bump) and to receive influenza and pneumococcal vaccinations. We are currently in the midst of a large influenza season, according to CDC estimates, there have been between 32-45 million cases of influenza this season, with 18,000 to 46,000 related deaths.

One fact—gained from outbreaks across the last century and into this one—is that the need for ready and trained health care professionals trained in the management of infectious diseases will be great. In fact, with the increasing spread of COVID-19, the need for readily available expertise in infectious diseases has never been more critical.

In addition to providing important expertise into the management of this infection, our role in educating the public—in many cases providing an important perspective when fears tend to run high—is also essential.

As we learn more, the novel coronavirus outbreak will continue to underscore needs for a health care workforce trained in infectious diseases, ready to rapidly respond to emerging and evolving public health and patient safety threats.

For that reason, policymakers should act to ensure the availability of infectious diseases physicians and other health care providers, scientists, and public health practitioners, to prepare for and respond to this, and future, outbreaks.

The challenge of COVID-19 must be met with appropriate resources that include intensified investment in global and domestic health security measures, and in our public health infrastructure. We must strengthen our ability to monitor and contain infections, treat those who become infected, and ensure full access to all essential medical services.

We must work rapidly toward developing a vaccine, treatments and diagnostic tools. We support frontline providers, scientists and public health professionals who work to save lives, contain the spread of disease and inform responses to this devastating threat to lives, health, stability and security worldwide.

This calls for a unified approach from all sectors of society.

It is still too early to make predictions about the outcome of COVID-19. This illustrates the need to always be vigilant for possible outbreaks.

An infection occurring anywhere in the world is only a plane ride away from any city in any country.

Thomas File is chair of the Infectious Disease Division at Summa Health in Akron, Ohio and professor of internal medicine, master teacher, and chair of the Infectious Disease Section at Northeast Ohio Medical University. After graduating from medical school at the University of Michigan, Ann Arbor, in 1972, File received his Master of Science in medical microbiology from Ohio State University in Columbus, in 1977, where he also completed his fellowship in infectious diseases.File is president of the Board of Directors of the Infectious Diseases Society of America (IDSA) and past president of the National Foundation for Infectious Diseases (NFID). He is a master of the American College of Physicians, a fellow of the American College of Chest Physicians, and a member of the American Thoracic Society. He is a past chairperson of the Standards and Practice Guidelines Committee of the IDSA and served as a member of several guideline panels. He is a past-president of the Infectious Disease Society of Ohio.Primary research interests that File has pursued include respiratory tract infections, immunizations in adults, antimicrobial stewardship, and evaluation of new antimicrobial agents. A frequent lecturer nationally and internationally, he has published more than 250 articles, abstracts, and textbook chapters, focusing on the diagnosis, etiology, and treatment of infectious diseases, especially on respiratory tract infections and antimicrobial stewardship. He received the Watanakunakorn Clinician Award from the IDSA in 2013 and the John P Utz Leadership award from NFID in May 2017. He authors sections on community-acquired pneumonia, acute bronchitis, and hospital-acquired pneumonia in UpToDate. He is Editor-in-Chief of Infectious Diseases in Clinical Practice.