Our response to COVID-19 is by far too little too late. We seem to be at risk of entering into a blame game and “politicizing” the problems. Our response to this contagion shows severe flaws in our healthcare delivery system. As one government official stated, “We have for whatever reason and there are many good ones, designed a system based on very lean staffing practices based on just-in-time supply chains and purchasing.”

In a March 5, 2019 USA Todayreport, a principle director of the CDC stated that healthcare facilities are “wondering whether it’s worth their trouble” to take action in preventing infections from dangerous pathogens such as MRSA1. This lack of attention to infectious disease prevention has set the stage for the United States’inadequate response to COVID-19.

Currently, we are facing shortages of testing kits2. Production is expected to rapidly increase but it is not clear when we will have an adequate supply. The lack and delay in testing has resulted in delayed identification of those infected and increased the spread in the community to where containment strategies have been severely hampered. Containment is crucial to slow the epidemic, so our healthcare system is not overrun with patients.

The lack of personal protective equipment (PPE) is also a significant problem3. A March 3, 2020 National Nurses United Survey reported only 63% of nurses had access to N-95 respirators on their unit. Only 30% report their employer has sufficient PPE for a rapid surge in COVID-19 infections (38% do not know). And 33% report they have not been fit tested in the last year. Only 29% report there is a plan to isolate suspected patients and only 65% have been trained in the proper donning and doffing of PPE.

Much of the CDC’s March 5, 2020 Healthcare Infection Control Practices Advisory Committee meeting concerned contingency plans involving the extended use and reusing (by the same healthcare worker) of PPE. Along with the use of out-of-date PPE, much of which is feared to be in our strategic emergency stockpiles.

The United States Fragile Supply chain of PPEs, medical equipment and pharmaceuticals is further put at risk by our overwhelming reliance on China for manufacturing. As aptly pointed out by Rosemary Gibson, author of China Rx, 80% of key pharmaceutical ingredients come from China4. Much of our medical supplies also are manufactured in China. We have no one to blame for this but ourselves. As stated in a Health Watch USA YouTube comment by a Chinese Pharmaceutical Industry Employee: “OK. The Chinese did not put a gun to US pharma manufacturers' heads and say ‘move all your production to China’.”

There is also little redundancy in hospital rooms and equipment. Even strategies of placing two people on one ventilator are being formulated5.

The lack of sufficient staff is a significant problem. There is little difference in the responsibility between nurses and other front-line responders such as the police and firefighters. Society expects the same degree of commitment and sacrifice. However, there does not appear to be the same degree of worker protection. Firefighters and police have work-related disability benefits, an economic safety net if they are injured or die during work, and they have access to ample protective equipment. If a nurse becomes ill with an infectious disease, it is usually not considered work related and they usually have to use sick leave. But even this benefit is not available to all workers. To a large part, nurses and infection preventionists have been treated as if they are disposable.

In public hearings and peer reviewed publications, Health Watch USAsmhas called for an economic safety net for screening of healthcare workers for dangerous contagions. At a minimum the following is needed6:

The screening of patients and healthcare workers for dangerous contagions to reduce the spread to families, other patients, staff and the community.

Establish a surveillance system for healthcare workers to determine the extent of occupational acquisition and infections of dangerous contagions.

Establish an economic and healthcare safety net for healthcare workers who become infected or colonized with dangerous contagions.

Sick leave benefits also need to be expanded to all workers in every economic sector. In Kentucky, only 62% of private workers have sick leave benefits. The Governor has called for universal coverage6.

In Nursing Homes, the situation is even worse. There is little regulation and the presence of an infection preventionist is not required. In an attempt to improve the situation, the CDC has proposed Enhanced Barrier Precautions. However, these fall short in regards to the CDC’s Urgent and Serious Threats. They are relaxed barrier precautions compared to contact isolation and we are concerned regarding their effectiveness in protecting the healthcare worker and patients7.

The COVID-19 resident deaths in Washington state’s Life Care Center of Kirkland may be a harbinger of the perilous challenges the nursing home industry will be facing. If we learn nothing else from the COVID-19 outbreak we should at least take home the message that half-baked and watered-downprecautions will not work. The pathogens do not care and are out to win. Nursing homes should be required to have an infection preventionist and will need to drastically improve their infectious disease strategies, incorporating isolation and if necessary, zone isolation. In addition, nursing homes will need to test a resident’s microbiome and make sure it is compatible with other residents in the facility. In the future, it may be the microbiome and not the family which chooses the nursing home.

Similar to what was done in the 1918 Spanish Flu pandemic, institutions such as nursing homes may need to implement reverse isolation strategies.

If staff shortages occur, the CDC has taken the unusual step of recommending facilities consider allowing a healthcare worker who is asymptomatic with a low or medium risk of exposure to come to work8. Since deaths are infrequent in healthy individuals under the age of 40, it may be an effective strategy to assign younger healthcare workers to COVID-19 care responsibilities9.

Finally, the United States needs to enact universal healthcare10. This is not a political statement, the politicians can decide how. But we will never control an epidemic in the United States if over 10% of the population does not have access to healthcare. We all live in the same fishbowl and we all are dependent upon and need each other.

Disclaimer: Recommendations regarding COVID-19 are very fluid as we learn more about the virus. Providers should consult their State Health Departments, CDC and WHO website on a regular basis for up to date information and changes in recommendations.

References:

(1) O’Donnell, J. Hospitals know how to reduce or stop staph infections. So why are thousands still dying? 2019. https://www.usatoday.com/story/news/health/2019/03/05/mrsa-staph-infection-hospital-deadly-centers-disease-control-medicare-medicaid/3032939002/

(2) Chen C. I Lived Through SARS and Reported on Ebola. These Are the Questions We Should Be Asking About Coronavirus. Propublica. March 5. https://www.propublica.org/article/i-lived-through-sars-and-reported-on-ebola-these-are-the-questions-we-should-be-asking-about-coronavirus

(3) National Nurses United March 3, 2020 Survey.

https://act.nationalnursesunited.org/page/-/files/graphics/0320_NNU_COVID-19_SurveyResults_030420.pdf

(4) China RX: Is Our Drug Supply Safe? Rosemary Gibson. Jack Pattie Show WVLK AM. June 21, 2018 https://youtu.be/K6sqjBoWMm4

and Sept. 25, 2019. https://youtu.be/K6sqjBoWMm4

(5) Martinex D, Breslauer B, Gosk S. Top hospital braces for coronavirus pandemic with secret warehouse full of emergency supplies. Accompanying video. March 4, 2020. https://www.nbcnews.com/news/us-news/top-hospital-braces-coronavirus-pandemic-secret-warehouse-full-emergency-supplies-n1149976



(6) Kavanagh KT, Abusalem S & Calderon LE View point: gaps in the current guidelines for the prevention of Methicillin-resistant Staphylococcus aureus surgical site infections Published: 18 September 2018. https://aricjournal.biomedcentral.com/articles/10.1186/s13756-018-0407-0



(6) Miller A. Gov. Beshear urges Kentucky employers to offer paid sick leave amid coronavirus fears Courier Journal. March 4, 2020. https://www.msn.com/en-us/money/companies/gov-beshear-urges-kentucky-employers-to-offer-paid-sick-leave-amid-coronavirus-fears/ar-BB10Hp9C



(7) Kevin Kavanagh, MD, MS Public Comment CDC HICPAC Meeting, Nov. 14, 2019. View YouTube Video: https://youtu.be/Gijk606uY9E

Download Written Comment http://www.healthwatchusa.org/HWUSA-Presentations-Community/PDF-Downloads/20191114-Public_Comment_Kavanagh-2.pdf



(8) Centers for Disease Control and Protection. Healthcare Infection Control Practices Advisory Committee meeting. March 5, 2020. And Healthcare Personnel with Potential Exposure to COVID-19 https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html



(9) China CDC Weekly. The Epidemiological Characteristics of an Outbreak of 2019 NovelCoronavirus Diseases (COVID-19) - China, 2020 http://weekly.chinacdc.cn/fileCCDCW/journal/article/ccdcw/2020/8/PDF/COVID-19.pdf



(10) Collins SR, Blumenthal D. Without universal healthcare, coronavirus puts us all at risk . Los Angeles Times. March 5, 2020. https://www.latimes.com/opinion/story/2020-03-05/op-ed-time-to-ramp-up-medicaid-to-pay-for-universal-coronavirus-care