JOHN DWYER. Understanding the public health imperatives required to minimise infection with the Corona virus. (Part Two).Mar 12, 2020
Providing communities with accurate, timely and logical information about the control measures required to minimise harms associated with infectious diseases is essential to avoid both complacency and panic.
Protecting the healthcare workforce from COVID-19
While concerns grow that Australia might experience a major epidemic, our delivery of high quality health care must continue. The potential for our health care workforce becoming infected is a serious concern. A health care professional, even with only mild symptoms, would remove themselves from normal duties for the two weeks they might be highly infectious. A confirmed infection in a GP could close a whole practice. We are in the unusual situation of needing to keep potentially infected patients away from their doctor.
The complicated logistics of doing this, while not compromising patient care, are being implemented. Australians with suggestive symptoms (runny nose, sore throat, fever and particularly shortness of breath) are being asked to phone their doctor for advice.
Although we all hate long recorded messages we are forced to listen to before we can push a button for our desired option, the tactic is warranted here. If you are put through to your doctor, a decision can be made about your need for a corona virus test.
Testing for infection with COVID-19
If you have recently travelled through a high-risk country (e.g., South Korea, Iran, Italy, China) and have any cold-like symptoms, you will be referred for testing. With mild symptoms and no likely contact with an infected individual, you will probably not be asked to be tested; your doctor will advise.
If referred to a specialised specimen collection centre, you will find the staff wearing personal protection outfits. A swab will be taken from your nose or throat. In theory, a result could be with your doctor within six hours. Unfortunately, we don’t, as yet, have the blood test available in many countries – it’s coming.
Some GP practices have “Do not enter if- – – ” signs at their front door. Pathology collection centres and emergency departments will increasingly have designated entrances for corona testing. For seriously ill people with a positive test, many hospitals are establishing special respiratory units with optimal treatment facilities and infection controls.
Such departures from normal arrangements inevitably have teething problems. Many GPs are reporting patients’ complaints about long waiting times on the phone and the over-worked phone system ‘crashing’.
Many doctors are suggesting that it would be reasonable for Medicare to immediately introduce a GP payment for corona-related telephone consultations. I have heard of doctors charging $90 for a phone consultation. Even in what is probably the early stages of a larger epidemic, talking to the worried well is increasingly onerous, but desirable. GPs’ non-medical health care professionals and staff need to be clearly advised and involved in patient communication and education.
State and Commonwealth responsibilities are now better integrated and peak professional bodies are having appropriate influence. You will not be surprised to know that providing all this in rural and remote communities is particularly difficult.
Preparedness for a worst-case scenario
While the majority of the confirmed infections with COVID-19 we are documenting in Australia involve individuals who encountered the virus while abroad, we are now seeing cases where Australians, who have not experienced recent travel have been infected and are infecting other Australians. This intra-community spreading of the virus is alarming as there is no doubt that it heralds a self-sustaining epidemic that will involve many episode of serious illness requiring intensive care in our hospitals. COVID-19-triggered pneumonia, kidney disease and heart failure need to be managed in intensive care units. Will we have enough beds?
The bed occupancy rate in our public hospitals in a normal winter is often 100%, with many beds occupied by patients with severe complications following infection with the Influenza virus. We Australians tend to call any winter cold “the flu”. Most winter infections are in fact caused by the relatively harmless, though annoying, common cold virus (another member of the Corona family). Real “flu” i.e. infection with the Influenza virus is a far more serious affair
We cannot be certain this early in the year, if 2020 will feature a particularly severe epidemic of influenza, but two signs are worrying: the severe influenza epidemic in the northern hemisphere last year and the fact that 12,000 cases of influenza have already been diagnosed here this year. Our peak months are usually August and September.
In the just finishing US winter, 16,000,000 people with influenza required hospital care. More than 16,000 died. In Australia between April and September 2019, in what was generally regarded as a mild flu season, there were 3732 people admitted to hospitals due to influenza, and of those, 237 (6.4%) required admission to an Intensive Care Unit .192 deaths were reported.
Faced with possibly huge demands for in-patient facilities to manage severe COVID-19 infections, a major preparedness strategy must involve efforts to minimise admissions for Influenza. We need a vigorous campaign to protect Australians from both Influenza and COVID-19. Hospitals will really struggle to provide adequate bed numbers for COVID-19 patients if we don’t reduce demand from patients infected with Influenza.
There is a family of Influenza viruses and not all members visit us every year. We do have vaccines that can offer protection from most members. Each year, scientists use the best available information to guess which sub-types will predominate in any given winter. They then cook up a vaccine to tackle those. Between 40 to 60% of vaccinated people are protected.
Each year we recommend influenza vaccination for everyone over six months of age while emphasising that people over 65 and those with respiratory problems have most to gain. This year however there are new imperatives requiring maximum participation of the community in the vaccination program. We need to ask Australians to be vaccinated not only to protect themselves but minimise the spread of the virus to those infected with COVID-19 and to reduce he normal pressures Influenza infection places on hospitals.
Although we normally start ‘normal’ influenza vaccinations in April, there is a good case for starting as soon as possible. The vaccine is available now (for a small fee), with free vaccination set for the middle of April.
A further thought about preparedness. Many countries are doing far more to test for COVID-19 among patients with any cold-like symptoms; as well as doing random testing to see extent of the of the virus’s penetration into communities. Recent studies suggest that, in some cases, infections were not associated with any symptoms, yet that asymptomatic person could be shedding COVID-19 particles. We need to do more testing.
While no one should be complacent about COVID-19, many are inappropriately worrying. Hoarding in case one faces a two week period of isolation is irrational and the focus on toilet paper bizarre. In case you were wondering only 2% of infections with COVID-19 are associated with diarrhoea!
Most of us will not be harmed by the virus. It will, however, challenge each of us to be part of an effective community response protecting those vulnerable to serious, even fatal consequences. What’s required is a terrible nuisance and disrupting to normal lifestyle. Unfortunately minimising social interactions is currently advisable for older Australians.
I suspect that COVID-19 will be around for years but currently required lifestyle changes will not continue once a vaccine is available. The scientific community has great confidence that an effective vaccine will be available sometime next year.
Professor John Dwyer is an Immunologist and Emeritus Professor of Medicine at UNSW.