Berks County Medical Society Medical Record Spring 2020 - 12

M e d i c a l R ec o r d F e a t u r e

The Next Pandemic Is Here
March 23, 2020

by Debra Powell, MD, Chief, Section of Infectious Diseases,
Medical Director for Infection Prevention, Tower Health Reading Hospital

T

he next pandemic is here. We are in the midst of the evolution
of the 2019 novel Coronavirus (COVID-19) outbreak that
was first identified in Wuhan, Hubei Province, China in
late December 2019. International travel has resulted in spread
of this infection globally and the numbers continue to increase
exponentially. The first US case was identified on January 21, 2020
in a patient who had recently traveled to Wuhan, China. The World
Health Organization (WHO) declared the outbreak a "public health
emergency of international concern" on January 30, 2020 and
the Health and Human Services Secretary followed by declaring a
public health emergency for the United States on January 31. The
World Health Organization officially named the current outbreak
COVID-19 on February 11, 2020. WHO declared this outbreak as
a pandemic on March 11, 2020. President Donald Trump declared a
National Emergency concerning the COVID-19 Outbreak on March
13, 2020.

Currently the rate of death is 3-5% of those infected.1,2 The total
numbers of cases are rapidly changing, and by the time this article
goes to press these numbers are anticipated to exponentially increase.
When this article was initially drafted on 1/31/2020, the WHO
reported spread to 20 countries with a total of 9,826 confirmed global
cases, including 6 confirmed cases in the US, with 213 global deaths.3
Within three weeks, on 2/21/2020, the numbers had increased to
76,769 confirmed global cases involving 27 countries with 2239
deaths. Due to the rapid progression, this article is being revised one
last time on March 23, 2020 before it goes to press. At this point in
time, the global impact is 292,142 cases with 12,784 deaths. More
than half of these cases are now outside of the Western Pacific area
with 152,293 confirmed cases and 7426 deaths in Europe. In the
United States there have been 15, 219 cases occurring in all 50 states,
with 201 deaths. In Pennsylvania, we have 4964 cases with 2 deaths.
Berks County has 13 positive cases, with more being diagnosed every
day,
Our lives have been significantly changed due to this pandemic,
with schools closing last week and now all businesses, except for those
considered life sustaining, being ordered to close. We have not seen
measures like this implemented in our lifetime. We have been asked
to avoid all groups larger than 10 people and have been encouraged
to conduct "social distancing," being at least 6 feet apart, to decrease
the spread of this virus. These measures have been implemented to
"flatten the curve" to decrease the trajectory of the outbreak. The goal
is to decrease the number of severe infections so as to not overwhelm
the health care system.
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What do we know about the virus to date? COVID-19 is a
betacoronavirus, which has its origins in bats. These viruses can
be spread to other animal hosts and then to man. Early in the
outbreak initial cases were associated with an animal market, but
subsequent cases have been attributed to person-to-person spread.
This coronavirus causes upper and lower respiratory tract infections,
and the majority of the most serious infections were in patients over
65 years of age or with co-morbidities. Incubation from exposure
to infection is 2 to 14 days with an average of 5 days. The illness
spans a spectrum from mild in up to 80% of patients - with no or
minor symptoms--to severe, causing pneumonia and death. The basic
reproduction number, Ro, is estimated at 2.4. This means that every
case of COVID-19 produces on average 2.4 secondary cases.
We initially were evaluating patients for travel history and
possible exposure. However, due to the rapid spread of this virus
over the globe and throughout the US, these questions are becoming
less relevant and by next week will be irrelevant. The current
recommendation for patients with fever and shortness of breath or
cough is to first call their primary care provider's office for advice.
Calling first is recommended so as not to expose office staff and
waiting rooms full of other patients to this virus. The office staff will
ask questions regarding symptoms related to COVID-19 infection.
Based on the severity of the symptoms, they are triaged for care at
either a designated Urgent Care Center that is set up for evaluation
of influenza-like illness, or to an Emergency Department if they have
more severe symptoms. The triage staff member will notify the Urgent
Care Center or Emergency Department of their anticipated arrival.
Enhanced droplet isolation with contact precautions should
be implemented and providers should wear appropriate personal
protective equipment (PPE) including a surgical mask, eye protection,
gown and gloves. For aerosol generating procedures, a N95 mask is
recommended instead of a surgical mask, with eye protection, gown
and gloves. Nasopharyngeal samples are obtained and placed into viral
transport media and sent for testing, either to a reference laboratory
or the PA Department of Health (DOH). The turnaround time is
approximately 3 - 7 days for the send-out laboratory test and 1 day
for the DOH. DOH testing requires prior approval and is reserved for
severely ill ICU level patients or healthcare workers.
We can learn additional information from prior betacoronavirus
outbreaks such as SARS (Severe Acute Respiratory Syndrome) and
MERS (Middle Eastern Respiratory Syndrome). SARS was first
reported in Asia in February 2003. The outbreak spread across North
and South America, Europe and Asia before it was contained. During
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