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DEPARTMENTS: Editorial

Tracking a Virus

Gould, Kathleen Ahern PhD, MSN, RN

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Dimensions of Critical Care Nursing: May/June 2020 - Volume 39 - Issue 3 - p 131-133
doi: 10.1097/DCC.0000000000000419
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Health security threats are not new. Influenza is a familiar viral infection that may share modes of transmission with a new novel virus; the 2019-nCov or coronavirus, most recently named Covid-19. This a new strain of coronavirus has not been previously identified in humans.

New viruses are always frightening as they often affect an immunologically immune population, while the evolution of the virus itself may not be readily identified. As the world tracks this new virus, which began in Wuhan, China, some positive outcomes emerge. There is a renewed discussion about vaccine safety, hand hygiene, and personal protection. And, there is significant evidence that much of what we teach and practice does work. Providers warn people to stay at home if you are sick, limit contact with others who are sick, cover your coughs and sneezes with tissues or with your inner elbow—not your hands or into the air, and wash your hands with soap and water for at least 20 seconds or use an approved disinfectant often.

Amid new fears and uncertainly, organizations, employers, and public health officials work to inform the public as they distribute information and enforce quarantine and travel restrictions. Employee travel advisories may require reentry physical examination requirements for persons returning from international travel.

Health care providers are key informants as they provide information and guidance as they share evidence and current information to best protect themselves, patients, and the public. Providers need to stay vigilant and informed. Information that is evidence based, measured, and accurate is essential. Local, national, international organizations work closely to inform providers and the public. Social media, scholarly publications, and all aspects of communication must be vetted. Disinformation and fraudulent reports are frightening and harmful. Many details about the virus are uncertain. Yet, epidemiologists continue to investigate its level of contagiousness, the spectrum of illness, and how to prevent transmission.

Epidemic and pandemics have the potential to eradicate thousands of people and devastate communities. The crisis is China was cloaked in secrecy blocking data collection, resources, and public health efforts. This complicates care in an already resource-constrained areas and presents a greater risk to countries with limited public health resources. However, we do have some experience with the spiky coronavirus and other viruses that are transmitted from animals to humans and advance to human-to-human transmission. Over the last 2 decades, 2 other suddenly infectious coronaviruses taught us a great deal. Severe acute respiratory syndrome (SARS) appeared in 2003, and spread to fewer than 9000 people over 4 continents, with only 8 cases in the United States, and MERS (Middle East respiratory syndrome), in 2012, which spread to more than 2000 people in 27 countries.1

Today, we are more connected to the rest of the world, and the risk for a global spread is a reality. Viruses cause the largest percentage of respiratory illness; they are endemic (always around) and may become pandemic or epidemic. A virus is very good at replicating itself, and any new virus is a challenge. Yet, our understanding of viral transmission, surveillance, epidemiology, and communication has also improved. Viruses often encode their genes in RNA of the cell—influenza is an RNA virus, as is a coronavirus, allowing it to replicate and mutate rapidly. Virulence is determined by many factors, including mode of transmission, genetic coding, and seasonal or climate factors. How this new coronavirus virus compares to seasonal flu, SARS, MERS, and the common cold is yet unknown. This virus may be as deadly as the Spanish flu of 1917 (also known as the Influenza of 1918), a pandemic that killed 2.5% of the population.2 Or, perhaps it will be more like seasonal flu that kills fewer than 0.1% of those it infects.2

Viral outbreaks that create respiratory illnesses are very difficult to control as people move freely around the globe. Any virus may become a global security threat. International disaster response teams, local hospitals and urgent care centers always dial up efforts to eradicate these common threats. Hospitals in the United States are organizing resources, educating staff, and updating existing emergency plans. Much of this work is organized around the 4 S's in relation to a surge in patients. These include supplies, staff, space, and systems that govern all of these things.3 Eileen Searle, the Bio Threats Clinical Operations program manager at Massachusetts General Hospital Center for Disaster Medicine, tells us this work includes all staff, as this type of protection and preparedness takes everyone. Searle understands that the fears of any community are real, and communication and information are crucial. A recent communication from one of the emergency physicians at MGH states, “We all value the importance of coordinated action because we want to make sure we are following the best science and doing the best for our patients.”3

These viruses, and all threats to public health, have implications that affect everyone. Yet, as fears spread about the new virus, many deaths in the United States are still attributed to influenza—a domestic concern that will continue to lead to illness and death, even as people resist vaccination against this known predator. These numbers are straining hospitals and care centers as surge units open in local emergency rooms and hot spots. During the first week of February 2020, the Centers for Disease Prevention and Control weekly surveillance estimates report at least 22 million reports of flu, 210 000 hospitalizations, and 12 000 deaths4

(https://www.cdc.gov/flu/weekly/fluviewinteractive.htm).

At the same time, the World Health Organization (WHO) has declared that the 2019-nCoV coronavirus is now a global public health emergency The US State Department issued a level 4 advisory, representing the highest safety risk. Recently, Johns Hopkins Center for Systems Science and Engineering published a website designed to track the trajectory of the 2019-nCoV outbreak and view live statistics using a global map, graphs, and run charts. These materials, and a companion blog, track the 2019-nCoV spread in real time. Cases and locations are viewed live, and real-time data are available for download. Updates appear several times a day and include data sources from WHO, Centers for Disease Prevention and Control, and the European Centre for Disease Prevention and Control.5 The JAMA Network set up a resource center for the 2019 novel coronavirus with research, updates, and education resources, including 2 video interviews with Tony Fauci. These are all free public access.6

In early February, the New England Journal of Medicine has made available a collection of free articles and other resources on the 2019 novel coronavirus outbreak, including clinical reports, management guidelines, and commentary. This collection includes editorials, audio interviews, and early analysis of the first cases confirmed in Wuhan, China. The site also displays a HealthMaps from Boston Children's Hospital, which tracks publicly reported confirmed and suspected case of 2019-nCoV globally. Additionally, historic articles about coronaviruses, such as SARS and MERS, appearing in the New England Journal of Medicine dated 2014–2003 are offered as free access.7

The SARS epidemic killed more than 800 people and hit the world economy hard. Ebola and Zika virus scares resulted in new methods of personal protection and improvements in isolation care. These lessons are embedded in our scholarly journals and media. As we prepare for this new threat, we should be well prepared. However, resource-constrained areas may face different challenges.

Hospitals are struggling to replenish supplies. Shortage of hospital beds, medical supplies, and health personnel is a persistent treat. Factories and manufacturing plants in the region are closed. Global supply chains linked to China are at risk. However, these are important containment measures and lessons learned from epidemics both local and national. The Great Influenza of 1918 is the United States was finally contained, only after these measures were in place. The definitive account of the 1918 Flu Epidemic is well documented. Much of the historical accounts center on the work done at Johns Hopkins! At the height of World War I, this influenza virus may have originated in an army camp in Kansas, moved east with American troops, and then exploded, killing many people worldwide. It killed more people in 24 months than AIDS killed in 24 years. But 1918 marked the first collision of science and epidemic disease. Historic accounts of virus transmission tell of triumph amid tragedy; each provides us with a precise and sobering model as we confront current challenges.8,9

As we prepare to combat Covid-19, information from reliable sources continues to arrive each day. On February 11, 2020, the Cochrane Library Special Collection pulled together the Cochrane Reviews that are most relevant to the management of people hospitalized with severe acute respiratory infections. These free-access materials feature Cochrane Reviews from 3 Cochrane Groups that are part of the Acute and Emergency Care Network to inform health decision making relevant to current WHO recommendations for the 2019 coronavirus outbreak. Cochrane reports that a second collection of reviews will be released soon as the situation changes to ensure ongoing relevance.10,11

Amid the fears and uncertainty, it is important to remember that WHO and other health care organizations do not have the force of law. Governments, organizations, and individuals make their own decisions about how to protect themselves. All of these groups need reliable and clear information.

Leaders in policy and health care strive to ensure safe and welcoming care, without bias or fear. Isolation policies must be logical, fair, and scientifically based. Dr Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, leads the effort to interfer with the natural flow of this outbeak. He provides education and explanation io ullistrate why aggressive public health responses may slow the progression of the virus and flatten the epidemic curve. Dr Fauci clearly states, “If you look at the curves of outbreaks, they go big peaks, then come down. What we need to do is flatten that down”.12-14

Health care leaders, scientists, frontline workers, and local and global organizations are committed to contain this new threat. Collaborative efforts in biomedicine and public health represent a unique opportunity for innovation. For our medical community, this is a call to re imagine and revise our public health system. We extend our sincere gratitude as they work to contain this new health threat.

References

1. Walsh B. Lessons from SARS: how to deal with the Wuhan coronavirus—and our new normal elemental. January 31, 2020. https://elemental.medium.com/lessons-from-sars-how-to-deal-with-the-wuhan-coronavirus-and-our-new-normal-f3bc5a7bb201. Accessed February 9, 2020.
2. Begley S. Experts see two scenarios if coronavirus isn't contained. Boston Sunday Globe. February 8. 2020.
3. Thielking M. We need everyone for this. STAT Health. February 7, 2020. https://www.statnews.com/2020/02/07/hospitals-harnessing-resources-brace-spike-coronavirus-cases/. Accessed February 9, 2020.
4. Centers for Disease Control and Prevention. Weekly US Surveillance Report. https://www.cdc.gov/flu/weekly/index.htm. Accessed February 9, 2020.
5. Johns Hopkins Center for Systems Science and Engineering. Coronavirus 2019—nCoV Global Cases Interactive Map. https://gisanddata.maps.arcgis.com/apps/opsdashboard/index.html?utm_source=Nature+Briefing&utm_campaign=ee09f96136-briefing-dy-20200130&utm_medium=email&utm_term=0_c9dfd39373-ee09f96136-44653105#/bda7594740fd40299423467b48e9ecf6. Accessed February 10, 2020.
6. JAMA. https://jamanetwork.com/journals/jama/pages/coronavirus-alert. Accessed March 1, 2020.
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8. Barry J. The Great Influenza; The Story of the Deadliest Pandemic in History. 2004. New York, NY: Penguin Books; 2005.
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10. Cochrane Library. Cochrane Special Collections: coronavirus (2019-nCoV): evidence relevant to critical care11 2020. https://www.cochrane.org/news/special-collection-coronavirus-2019-ncov-evidence-relevant-critical-care. Accessed February 12, 2020.
11. World Health Organization. Clinical management of severe acute respiratory infection when novel coronavirus (nCoV) infection is suspected. Interim guidance. 2020. https://www.who.int/publications-detail/clinical-management-of-severe-acute-respiratory-infection-when-novel-coronavirus-(ncov)-infection-is-suspected. Accessed February 12, 2020.
12. Qualls N, Levitt A, Kanade N, et al. Community Mitigation Guidelines to Prevent Pandemic Influenza — United States, 2017. MMWR Recomm Rep 2017;66(No. RR-1):1–34. DOI: http://dx.doi.org/10.15585/mmwr.rr6601a1.
13. Roberts S. Flattening the Coronavirsu Curve. The New York Times. https://www.nytimes.com/2020/03/11/science/coronavirus-curve-mitigation-infection.html. Accessed March 11, 2020.
14. Branswell H. Why “flattening the curve” may be the worlds best bet to slow the coronavirus. Stat News, Boston Globe. https://www.statnews.com/2020/03/11/flattening-curve-coronavirus/. Accessed March 11, 2020.
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