[Part-2] COVID-19: A point of no turning back

I had previously shared about the hope for treatment and prevention of Covid-19 and about the complacency of the US in trying to manage the outbreak. Today I will address the question: When do we completely lose this battle? When the number reaches 100 cases? 1000 cases? 1 million cases?

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In short, we lose when all the medical resources, including equipment and hospital beds, of the entire national system grow out of capacity to serve any additional life-threatening cases. Imagine if you have difficulty breathing or you present febrile convulsion, but at this moment, all hospitals have already been out of beds, of ventilators, of care, and you are left with the only option to go home. At this time, other hospitalized cases are as severe as yours, and unfortunately you have arrived too late.

In many cases (TH), young age does not guarantee recovery from COVID-19. As an example, the Chinese doctor and whistleblower Li Wenliang was medicated with antibiotics and antiviral drugs, along with assisted breathing through artificial lungs. Regardless, he passed away at the age of 34. So, when we look at the high percentage of recovery, it does not necessarily mean all of them have recovered on their own chance. A percentage of this young infected population has received extensive and timely medical intervention.

How not to lose?

After the first cases were recorded, it took China about 3 weeks to arrive with an action plan. China would have lost control of the outbreak without the construction of field hospitals, enforcement of large-scale containment, and civilian cooperation in community isolation. The speed, efficiency and resilience of China has finally paid off despite a tremendous loss in human and economic resources. On March 11, the country recorded only 24 new cases, with 84% recovery of all infected cases. Those 80,000 cases of China constitutes a case study with a very large sample size, and the conclusion of the study has never been clearer: Containment is the only way to stop the pandemic.

In this lesson, the United States was behind. The US did not realize a pattern that when China and Italy offered testing their people en masse, the number of cases jumped exponentially. In China, there were 444 cases on January 23, just one week later the number jumped to 4903, and, one more week, 22,112. In Italy, similarly, in 3 weeks these numbers were 62, 888, and 4636 respectively.

Thus, if the criteria to allow Americans to access COVID-19 test remain as strict as they are now, 1,300 US cases are clearly just the tip of the iceberg. In particular, I would like to mention the following three recent studies:

(1) In this study in the New England Journal of Medicine, an index patient infected with Covid-19 still presented a high viral load even at end of symptoms: https://www.nejm.org/doi/full/10.1056/NEJMc2001468…

(2) Another study by a group of German researchers has made similar suggestion: SARS-CoV-2 virus has a prolonged shedding pattern that exceeds the end of symptoms

https://www.medrxiv.org/conte…/10.1101/2020.03.05.20030502v1. They also recommend that persistence of low viral load (<100,000 copies / ml) at 10 days after onset of symptoms is required to assess the risk of transmission in discharged patients..

So to affirm complete recovery, the patient must get tested for his persistently low viral load, and not by his symptoms alone. Unsurprisingly, you would expect articles reporting that discharged patients have come back positive for the virus despite their complete recovery of symptoms.

I would like to address the theory in the media about community immunity through spreading. Essentially, they hypothesize that the United States or Europe has intended to allow the spread of outbreak in order to create herd immunity: a “one sick, two happy” theory. I believe that when a hypothesis is written down, the first thing to do is to criticize our own hypothesis.

If you imagine that on the battlefield, two soldiers A and B fell down together, then the option to save whom would have nothing to do with their wealth or skin color. Given scarce medical supplies, why Soldier A gets saved not Soldier B is simply because of A’s better prognosis. If the doctor chooses to save B and cannot save B, then the time Soldier A waits for his turn can make A as critical and severe as B, and in the end, the doctor would lose both soldiers.

This choice is clearly in no one’s favor, but to win the battle, we have to save lives. Therefore, at this time some countries are "Prioritizing" resources for save-able cases, and they "surrender" on cases that would have low chance of recovery despite the same medical support. However, in parallel with medical prioritization, the country must be very aggressive in containment.

So when do we lose it?

By limiting access of the public to COVID-19 tests (because of shortage of testing kits or of strict criteria), the US might not realize that they are sacrificing containment of the outbreak. We lose when hospitals simultaneously record an exponential increase in the number of severe and critical cases, with a higher death rate in the US compared to global average, as in Italy now. Only then would the US realize they have made a big mistake not containing the outbreak timely and effectively.

On Wednesday, China has agreed to send experts, medical supplies and equipment to assist Italy. Given the sense of American exceptionalism and Trump’s uncanny ability to burn diplomatic bridges, who would come to America's aid?

If you still think that US healthcare system is #1 in the world, it is indeed #1 in the world in terms of complexity and cost. Yet, the number of hospital beds per 1,000 people in the US is 2.4, lower than Italy (3.2), China (4.3) or Korea (12.3), countries that are still struggling to control the epidemic. Currently the US has about 46,500-95,837 ICU beds and ~ 160,000 ventilators according to American Hospital Association and Johns Hopkins. If the COVID-19 pandemic spreads only moderately, the healthcare system would need at minimum 1 million beds and 200,000 ventilators (Johns Hopkins).

Without effective containment, America will surely lose against COVID-19.

Conclusion

Community isolation via social distancing is the very least a country must do to prevent the spread of epidemics, reduce deaths and protect its own healthcare system. In this battle, if you cannot fight and win quickly, then you must try to survive the longest. In order to survive, you must give everyone the opportunity to test for the novel virus regardless of the need for medical intervention.

Every health crisis tests the strength and resilience of a healthcare system. Hopefully the US will weather this storm, and the president of 2020 would never give public health advice based on his hunches. Never again.