The coronavirus epidemic is rapidly escalating in the United States. In addition to social distancing measures, such as canceling public events and working from home, we need a health system strategy premised on testing, telehealth, and treatment that achieves the twin objectives of curbing transmission and optimizing care for the influx of patients expected in the coming weeks.
With the epidemic doubling in size every week, we need to act urgently and, within the next 30 days, establish a systematic approach to find and isolate infected people as quickly as possible before they infect others, monitor Covid-19 patients with mild illness at home, and preserve limited hospital capacity for those who really need it.
If we knew every single person infected at this very moment, we could isolate and treat them before they infect others, and this epidemic would be over in a matter of weeks. However, because Covid-19 causes symptoms similar to the flu and numerous other viruses, it is impossible to know who is infected without testing.
To more effectively and quickly detect cases, we need to test large numbers of people. Anyone with symptoms that may reflect Covid-19 infection needs to be tested. To give some idea of how many people this may include, the flu infected about 10% of the U.S. population last year — more than 30 million people.
Testing large numbers of people in hospitals and doctors’ offices, where infection could inadvertently spread, is not a good idea. Sites capable of tests that use the polymerase chain reaction (PCR) technique should be established in every town, suburb, and borough, with sample collection points set up in neighborhoods and smaller communities so people can get testing without delay or an appointment. These sites can be set up as drop-in, walk-through or — as is being done in South Korea, the United Kingdom, and now Seattle and Nevada — drive-through centers where trained personnel with protective gear can, in about 10 minutes, assess patients and obtain nasal swabs from those with concerning symptoms. These swabs can be sent to PCR testing labs, and patients can then be notified of the results by phone. While awaiting results, patients with mild symptoms can be advised to quarantine themselves at home. Others already with signs of serious illness should be sent immediately to a hospital.
For people unable to seek testing on their own, such as the homebound elderly, trained staff from local health departments should be dispatched to their homes to collect samples. People should also be given the option of receiving home testing kits that allow them to swab themselves and mail in samples for testing.
Ultimately, the challenge of mass testing can be streamlined with a rapid diagnostic test that, akin to over-the-counter urine pregnancy tests, can even be self-administered and can provide results within minutes. Though several rapid tests are being developed, it is not clear when any will be ready for use. However, with the epidemic growing quickly, the need to scale up and speed up detection can’t wait for a rapid test and need not — China was able to turnaround PCR results within the same day compared to the 48 hours or more it has been taking in the United States.
Telehealth response centers with 24/7 call-in lines staffed by nurses should be established within each local public health department. People with concerning symptoms can call in to be assessed and, if deemed necessary, referred for testing. These nurses should follow up with all patients with positive test results. Patients who appear to be developing serious illness — about 20% of all cases — should be transported by ambulance for higher-level assessment and care at a local hospital.
The roughly 80% who only have mild symptoms can remain in home isolation and counseled on caring for themselves and preventing the spread of the virus to others, including ways to disinfect shared spaces in the home. Similar to the way poison control centers that already exist in each state remotely monitor people who have ingested a toxic substance, telehealth centers should periodically check on these patients and refer any patients who evolve more concerning signs to the hospital. This monitoring can be enhanced with FaceTime or Skype and devices that allow remote tracking of vital signs such as Fitbit or Apple Watch.
About 20% of patients will require care only possible in hospitals; 5% will need care in intensive care units (ICUs), including intubation and placement on ventilators. Even with steps to admit only those patients who truly need hospital care, capacity for isolation and ICU care may quickly become overwhelmed. Reports from Italy describe hospitals drowning with critically ill patients.
The same health system failure can easily happen here. For example, California has about 80,000 hospital beds. If even 1.5% of the state’s 31 million adults were infected — a plausible scenario that is far less than both the 10% infected with the flu this year and the adult infection rate of 20% or more that one leading epidemiologist is predicting — Covid-19 patients would take up every hospital bed in the state.
Immediate contingency planning and federal funding is needed to quickly provide hospitals with surge capacity for space, staffing, and key equipment. Hospitals should have turnkey plans for converting existing non-clinical spaces, such as conference rooms, into isolation wards. They should also identify other buildings such as public offices and empty warehouses that can be used if needed.
State and local health departments should review staffing plans with local hospitals and begin allocating funds to hire additional staff as well as provide bonuses for those willing to take on more shifts. Family doctors and internists — the two most common specialties in the United States — typically spend substantial time in ICUs while in training and should be provided with refresher training on managing ventilators to boost the ranks of those ready to care for sick Covid-19 patients.
The federal government should immediately incentivize companies involved in producing specialized equipment needed for Covid-19 patients such as ventilators to accelerate manufacturing. State and local health departments should coordinate the purchase and allocation of equipment depending on where needs are.
This systematic chain of testing, telehealth, and treatment should be directed by state health departments, with local health departments managing ground-level implementation. Epidemics are notorious for constantly changing with hot spots dying down in one place only to arise in others. State departments should quarterback the allocation of resources across counties as the epidemic evolves.
At the federal level, the Centers for Disease Control and Prevention (CDC) should deploy expertise where it is needed, provide state and local teams with technical guidance, and disseminate best practices from around the country and globe. The National Institutes of Health (NIH) and the Biomedical Advanced Research and Development Authority (BARDA) should lead the research and development of new knowledge and tools needed to better respond.
The Covid-19 epidemic poses a once-in-lifetime challenge that is already causing widespread panic and economic paralysis. While the epidemic appears to be spiraling out of control now, if we take these steps in the next 30 days, we can meet the challenge posed by coronavirus.