JARED KALTWASSER
As SARS-CoV-2 continues to spread around the world and testing rates vary widely from state to state and country to country, a new article in the Journal of the American Medical Association argues that public health officials must shift from a "containment" mindset to a "mitigation" mindset.
Stephen M. Parodi, MD, and Vincent X. Liu, MD, MSc, both of Kaiser Permanente's Permanent Medical Group, say that a containment strategy is becoming increasingly difficult as officials are less and less able to identify the sources of particular cases.
"When a small number of infected patients are in concentrated locations, containment strategies (i.e., quarantine) can stop the spread of infection by isolating infected or exposed individuals from the general population," they write.
However, doing so requires an all-hands approach and the full strength of a large number of healthcare workers using personal protective equipment and isolating patients in wards.
However, the initial inability to gain a clear understanding of the situation has already meant that many healthcare workers have been exposed, requiring them to be quarantined and excluded from their medical duties. A major reason for this is that around 80% of people infected with the virus show few or no symptoms.
This situation makes it extremely difficult to assemble a full-force containment approach, Parodi and Liu argue.
"Given that COVID-19 is spreading so much in the U.S. and around the world, it may not be possible to serve all patients in this way," they note.
Instead, Parodi and Liu say, public health officials should shift to a mitigation strategy.
They define the strategy with five key characteristics: Slowing the spread of the virus; Reducing the expected increase in the use of health care; Providing adequate care to allow most patients to recover with time-limited home isolation; Expanding testing and hospital capacities; and Adapting isolation situations to limit the spread of the virus.
"Without the rapid adoption of these approaches in hospitals, COVID-19 will pose a critical risk to an already strained health care system," Parodi and Liu say.
The authors go on to outline the plan Kaiser Permanente has been developing to mitigate the impacts of the virus. They say the goal is to minimize virus transmission within the acute care setting.
Since the virus appears to spread through droplets , Parodi and Liu said that healthcare workers will protect themselves with surgical masks, disposable gowns, gloves, and protective goggles.
"This approach is intended to simplify workflow and preserve the use of enhanced airborne transmission precautionary equipment such as N95 masks and powered or controlled air-purifying respirators for patients with diseases such as tuberculosis," they say.
Additional protective equipment will be used in high-risk situations, and all single rooms in the hospital will be available to accommodate droplet isolation.
The plan requires that patients with no symptoms or mild symptoms stay at home and be treated by telemedicine as much as possible.
Meanwhile, designated sites would be established specifically for the evaluation and testing of patients with suspected cases of COVID-19.
For healthcare workers, the proposed plan requires a similar approach to that used for influenza. If a worker is exposed to patients with suspected or confirmed COVID-19, they should self-monitor, Parodi and Liu write.
"If they become ill and it is confirmed that they do not have COVID-19, staff will remain off work until their fever resolves and their other symptoms begin to improve," they say.
"Healthcare workers with confirmed COVID-19 should be off work according to CDC guidelines."
The authors conclude that they believe the healthcare system still has the ingenuity and skill to gain the upper hand against the virus, and say that consistent planning will be an important part of that process.
"Clear guidelines shared between hospitals and states could help improve the ability to maintain a capable and sustainable approach for all patients," they say.