Arundhati Roy observed: “Historically, pandemics have forced humans to break with the past and imagine their world anew.” I however, have set my expectation lower for COVID-19, hoping that this pandemic will provide the motivation to make the changes we always knew needed to happen, but lacked the political will and motivation to implement them.
The United States’ failed response to the COVID-19 pandemic is multifaceted and started with a lack of infectious disease infrastructure and the failure to learn from outbreaks of multi-drug resistant organisms (MDROs) and past epidemics. Of overriding importance, was a failure to conceptualize that we all live in the same biosphere. Whether we are confronting global warming, antibiotic resistance, or a pandemic; everyone’s actions affect the health and welfare of all. We cannot hope to control the spread of infectious diseases without international cooperation and universal access to healthcare.
That We Need to be Prepared and Maintain a Robust Infectious Disease Infrastructure
Over the past two decades, the world has seen major epidemics from EBOLA, SARS and MERS. Singapore learned from experience and upgraded their infectious disease infrastructure, Their stockpile housed almost three N95 masks per resident at the start of the COVID-19 pandemic, although not every country was so well prepared.
The United States went in the opposite direction and stepped back from its leadership role in pandemic preparedness and response, largely ignoring the advice of its scientific community. CDC funding was cut in 2019 and had a projected decrease for 2020, From 2017-2020,, the CDC’s China staff was slashed from approximately 47 to around 14 individuals, including epidemiologists and other health professionals.
In the Spring of 2018, the United States’ pandemic response team was disbanded and its activities were largely reassigned to other agencies. Crimson Contagion, a pandemic response scenario, predicted a confused uncoordinated response, which aptly foretold what took place. Our strategic reserves of N95 masks were all but depleted but even at maximum capacity, the stockpile was only designed to provide 2.4% of the projected need for 3.5 billion masks.
Testing and Surveillance of Community Spread is Key to Stopping An Epidemic
Early detection of community spread is vital to generate the ‘Data-for-Action’ which is needed to stop the spread of dangerous pathogens.
During the Ebola epidemic of 2014, the Government of Guinea, changed the case definition by requiring a positive laboratory test to diagnose an infection and document spread. The country had limited testing capability and because of this, the number of reported cases fell. The world thought the epidemic was under control, but instead it spread into surrounding regions and countries, undetected by response agencies throughout the word.
Similarly, the United States had inadequate testing early in the COVID-19 pandemic. The virus entered our pacific Northwest. A decision was made not to adopt the World Health Organization test which was developed in Germany, and prohibit independent labs from performing Laboratory-Developed Tests. Instead, the United States was to rely on a test developed by the Centers for Disease Control and Prevention (CDC), which was found to be defective. This resulted in a limited testing capability and restrictive criteria on when to obtain a test. Asymptomatic spread was not detected, and the virus spread throughout communities in the United States.
The United States has limited data on community spread for all of the pathogens listed by the CDC as Urgent and Serious Threats. For the most part, what we know is based upon small studies which generate data from skewed populations admitted or seen within our healthcare system, and there is even limited data regarding MRSA, the most common organism responsible for dangerous co-infection in COVID-19 patients. The CDC does collect data regarding MRSA infections which occur within the first three days of hospitalization; this data is felt to be a surrogate for community infections, but it is not released to the public.
CDC guidance was also changed to no longer recommend screening for asymptomatic SARS-CoV-2 carriers. There was a resultant outcry from public health officials regarding how ill-advised this was; and who quickly retorted that without knowing community spread and identifying asymptomatic carriers, one could not control the pandemic. The CDC quickly revised their guidance again and recommended testing for asymptomatic carriers, but in the United States, the opposite holds true for prevention of Methicillin-resistant Staphylococcus aureus (MRSA). There is opposition to identification of carriers and the screening of patients on admission to hospitals, and even with isolation and decoloniziation of those who harbor the organisms (for more, click here, here and here).
The Need for a National Reporting System for Dangerous Pathogens
A major deficiency in the United States’ infrastructure was the absence of a national reporting system for infectious diseases. In 2012, the requirement for hospitals to keep an infection control log was eliminate, and the excuse given was that hospitals already track infections through other reporting systems.
However, of the CDC’s five contagions designated as ‘Urgent Threats’ only Clostridioides difficile is mandatorily reported on a national level, and of the ‘Serious Threats’ only Methicillin-Resistant Staphylococcal Aureus (MRSA) is mandatorily reported on a national level and only for acute care hospitals.
One of the key lessons from this pandemic is the need to implement a mandatory National Reporting System for all dangerous pathogens which encompasses all types of healthcare facilities and providers. This has been accomplished for SARS-CoV-2, and the same should be true for all of the CDC’s ‘Urgent’ and ‘Serious Threats’. A national reporting system needs to encompass all types of infections and co-infections. In addition, specific types of infections including catheter-associated urinary tract infections, central line associated bloodstream infections and ventilator associated infections need to be reported.
The system also needs to be real-time and transparent. In response to COVID-19, nursing home interim guidance in the United States requires facilities to, “Inform residents, their representatives, and families of those residing in facilities by 5 p.m. the next calendar day following the occurrence of either a single confirmed infection of COVID-19, or three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other.” The same needs to be true for all dangerous pathogens in all types of healthcare facilities.
What lessons have been learned?
Many lessons have been learned from COVID-19. We have learned that case definitions can be rapidly created and a reporting system which comprises all types of healthcare facilities can be implemented. The same needs to be done for other dangerous pathogens, including the CDC’s Urgent and Serious Threats, and strategies need to be standardized across all types of facilities. SARS-CoV-2 does not vary its lethality or infectivity based upon the facility type or region of the country.
South Korea embraced public health strategies early on and to date has lost less than 500 residents in their country. If the United States would have followed this strategy early on, it would have lost approximately 3000 individuals (corrected for population), a far cry from the over 220,000 residents which have died from COVID-19.
Every citizen needs to care for and protect others. In the prevention of infectious disease, the old mentality needs to be abandoned. This means the adoption of a national strategy which has robust contact tracing and contacts being willing to self-quarantine.
Of utmost importance in controlling this pandemic, we need a robust infectious disease infrastructure, a national reporting system for all dangerous pathogens to allow for strategic resource production and allocation, along with extensive contact tracing for SARS-CoV-2 and contacts being willing to give up personal freedoms and self-quarantine for the benefit of others.
This post is by Dr. Kevin Kavanagh, and originally appeared on the BMC blog network.