COVID-19: Why I'm very concerned

While it’s well known that China and Iran have under-reported their COVID-19 statistics, Italy has been fully transparent. What we are learning is very concerning. The Lombardy province alone has experienced a surge in deaths due to the coronavirus— from 20 to 66 deaths in just one day. Analyzing data for the country as a whole, new diagnoses and deaths are doubling every few days. At this rate, Italy’s entire healthcare system will be overwhelmed by next week. Remember that two weeks ago, Italy had reported seven deaths.

Italy is a preview of what we may see in the U.S. very soon.

In a recent statement, the American Hospital Association projects strain on U.S. hospitals and is requesting congressional funding for new hospital construction and increased housing for patients. Doing the math, the U.S. currently has approximately 100,000 ICU beds with most hospitals already functioning at full or near-full capacity. According to the Johns Hopkins Center for Health Security, 200,000 to as many as 2.9 million patients could present to U.S. hospitals with coronavirus. It’s time we increase the capacity of our medical centers before the infection ramps up.

Wuhan was overrun even with 19 field hospitals set up for the pandemic. Healthcare workers are at the highest risk of getting infected, not only representing a risk to our lives but a strain to our capacity to care for the tsunami of patients expected. U.S. hospitals and health professionals are on track to soon be overrun with patients, following the pattern of hospitals overseas who describe rationing respiratory support. Within weeks, U.S. hospitals may be significantly under-resourced and deal with major staffing shortages. Washington State is already scrambling to hire hundreds of travel nurses to help staff the influx of infected patients.

If the virus stays on its current trajectory, what happened in Wuhan will happen in the U.S. There is no strong scientific argument to suggest otherwise. While we all hope the virus demonstrates an unexpected heat-sensitivity or mutates to a less virulent form, the virus has, so far, followed a highly predictable course. That path was mapped out over three weeks ago by Marc Lipsitch, PhD, of the Harvard T.H. Chan School of Public Health. Despite his dire warning that 40%-70% of the population could be infected, little was done to prepare for the pending crisis beyond standard handwashing and coughing instructions — a routine done every flu season. We need to mobilize quickly. In a national survey of 6,500 nurses in 48 states released last week, 63% of nurses report that they do not have access to N95 respirators in their units, and many said they haven’t been fitted or trained on how to properly use them. At the same time, first responders are underprepared, and most have not been given the protective gear they need to treat infected patients.

Unfortunately, we live in an era of people spouting opinions on social media and cable news with no knowledge of a topic. TV pundits with no knowledge of virology, public health, or pandemic history are crowding out medical experts. Twitter, which promotes shouting over listening, is also loaded with comments ignorant to the data. News networks should push aside legacy political commentators and put infectious diseases physicians on the air to warn the public about the pandemic. Now more than ever, physicians need to speak up about the pending health crisis in the U.S.

Arguments about the exact case fatality rate (CFR) have become a distraction from the real issue at hand — preparedness. While it’s a worthy exercise to determine if CFR estimates are including mild or asymptomatic patients in the denominator, it does not change our need to prepare or how we treat individual patients. Data from Italy suggests the CFR may be as high as 3%-4%. Adding an assumption that roughly half of people with mild or no symptoms were not tested, it may be closer to 1.5%-2%, just below that of the 1918 Spanish flu pandemic which killed 30 million people. The Diamond Princess ship was a controlled case study: 705 people tested positive for the virus, and seven died, suggesting a 1% CFR, albeit a slightly older skewed population. Regardless of where the true CFR is between 1% and 3.4% as the WHO is reporting, this is, at best, at least ten times worse than a bad flu season and, at worst, a pandemic that could claim millions of American lives.

Further hindering public health efforts, the concept of American exceptionalism has morphed into a societal arrogance that somehow the immune systems of Americans are stronger than those of the Chinese. And even though other countries have enacted very strict quarantine practices, including martial law and a shutdown of schools, there is a misleading perception that the U.S. would have less community transmission because of a better health care system and better hygiene. Another barrier has been the exaggerated notion that COVID-19 is only a danger to old people and that young people are entirely resilient.

Italy has now quarantined approximately 60 million people, and closed all nightclubs, gyms, and sporting events. I respect NIAID Director Anthony Fauci and admired his leadership as a clinical voice of reason amidst of our AIDS, SARS, and Ebola epidemics, but I’m concerned he has not yet introduced contingency plans for any of these major preventive measures. Instead, he is re-iterating a popular view that there is a lot we don’t know and that anything is possible. His only strong warning has been directed to those considering cruise ship travel. Based on the current trajectory of the pandemic, all U.S. schools are at risk and may need to be closed, public gatherings like NCAA tournament games may need to be postponed, businesses should have their employees work from home whenever possible, and hospitals should staff up. I don’t like it, but that’s what the data are telling us to do.

At the current rate of spread, we can expect members of Congress, and even presidential candidates, to be infected with the virus within 6-8 weeks. In fact, President Xi Jinping of China has not been seen in public for weeks, and many of Iran’s leaders have the infection. Already, U.S. Sen. Ted Cruz and several House members have announced they will self-quarantine after shaking hands with an infected individual. Many more are likely infected, but we have been using a false pretense that confirmed cases are the only cases out there, despite the fact that testing has been extremely limited at best. It’s time we dispel the notion that this virus is somehow contained. It is at large.

The main talking points issued on this topic have been that we simply don’t know what this virus will do — but COVID-19’s course has already played out in other parts of the world. We just need to listen to data and put medical experts out in front of this instead of broadcasting opinions. We need to plan for the worst and hope for the best. Considering the implications for public health, and particularly for our older patients and those with underlying risk factors, we should act swiftly on the data rather than risk a delayed response we might regret.

Marty Makary is a surgeon and editor in chief, MedPage Today.

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