The coronavirus is not going away any time soon.
Hospital and health care workers know this all too well as they take extreme measures to preserve personal protective equipment and brace for an increase in patients with respiratory symptoms in the coming weeks.
Recommendations have been made – wash your hands, keep 6 feet of social distance, work from home – and mandatory measures in Washington have closed seating at all restaurants and shutdown gyms, barbershops and theaters and prevented people from gathering in groups of more than 50.
But will Gov. Jay Inslee’s two-week shutdown of social gatherings, six-week statewide school closure and a smattering of other temporary bans and prohibitions last long enough to flatten the curve of COVID-19’s spread in the state?
Likely not, health officials say.
So how long will these mitigation measures need to be in place?
“Not two weeks,” said Dr. Eric Lofgren, an epidemiologist at Washington State University. “I think my answer for this is, as much as we can for as long as we can, because we will start seeing impacts in other aspects of society, like how long can you keep that restaurant closed before it closes for good?”
Using President Donald Trump’s likening of the fight against the novel coronavirus to a war, Dr. David Line, director of the public health program at Eastern Washington University, says we’re in for a long slog.
“We’ve lost the first set of battles, so we need to anticipate that even though we are ramping up and doing the right things, we are going to lose ground,” Line said.
Line points to the postponement of the NBA season as the moment the nation began to take the threat of COVID-19 seriously, and he wishes Major League Baseball would move cancel its season. He also would like to hear the NFL come out with plans for a 10-week season.
“It would go to: Are we really committed to doing this war where we will sacrifice our economy and lifestyle for a relatively long time versus going on a single campaign?” Line said.
Line is not alone.
Epidemiologists and modelers, including Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, estimate a viable vaccine will not be ready for 12 to 18 months. How long, realistically, can a community be shut down as Washington currently is? That question is one economists are wondering as well as the stock market falls. Simultaneously, thousands of people are filing unemployment claims, including in Washington.
“The thing that has the most impact on people’s health across the board and historically for many years is poverty,” Line said. “If we go into a great depression because we are trying to avoid the coronavirus and flatten this curve, that will have a dramatic impact on health for the next decade, so those are the complexities.”
In the present situation, Eastern Washington likely will not see the results of social distancing measures and isolation for a few weeks, in part due to the limited testing available to health care providers as well as what experts know about how the symptoms of the virus present themselves.
“When you look at hospitalizations, by the time somebody is sick enough to be seen in an ER and hospitalized, they are two weeks into the infection, based on the median time of infection and when people start to present symptoms,” Spokane Regional Health District Health Officer Dr. Bob Lutz said. “But we are just starting these mitigation efforts last week, so the people who are presenting to the ER today are people who were infected two weeks ago, so the only way we will see any, any possibility of flattening this curve is we’ve got to give it time.”
Currently, only symptomatic people who meet specific criteria are being tested, due to the short supply of testing kits, which makes identifying the community spread of the virus in Eastern Washington difficult.
“A nice strategy right now if we could afford it is to do a random sampling in the community across all ages and find out what percentage of the community actually have it. That would be great to know two weeks from now when we know how many show symptoms,” Line said.
The effort to expand testing will begin this week, with the loosening of a requirement that people need a doctor’s referral to go to drive-thru screening at the Spokane County fairgrounds.
But testing is likely to remain less than comprehensive.
Rural hospitals in the area are asking people to contact their health care provider first to see if their symptoms are severe enough before getting them checked in person.
The region could see its number of confirmed cases rise in the next couple weeks, as more people are tested, but mitigation strategies could also begin to combat the rise in cases.
“We’ve got to enhance the social distancing and in two weeks, as we see our numbers going up, maybe they won’t be going up as steeply, which would suggest that maybe what we’re doing now will have impact,” Lutz said.
Eventually, as confirmed cases increase, testing eventually could become a moot point, like it did in Seattle, where people who could manage their symptoms were not tested and instead told to treat them at home.
There are no approved drug treatments or vaccinations for COVID-19, and those in clinical trials now will take months to perfect and produce.
The Kaiser Permanente Washington Health Research Institute received federal approval to start the clinical trial for a vaccine on March 16, with 45 healthy individuals in the Seattle-area. The trial is expected to take 14 months, however, as it involves multiple phases. Clinical trials for drug treatments, like remdesivir, are underway but will also take several months to complete.
This leaves widespread mitigation strategies as the most effective way to slow the spread of the virus, to help answer the question, “Can we make the epidemic smaller and spread it out and cushion the impact of the epidemic itself?” Lofgren said.
Mitigation strategies buy hospitals precious time to make room for patients, as well as time for researchers to develop treatments and, in several months, a vaccine.
In the meantime, health officials are warning the next few weeks and months could look very different for our community. There are currently 16 confirmed cases in Spokane, although Lutz expects there are more. Many counties in Eastern Washington have dozens of test results pending.
“When you’re looking at trying to provide a sufficient period of time to see if these non-pharmaceutical interventions will have impacts, two weeks is not sufficient,” Lutz said. “A month would get you into the next cycle of infection, but then you’ve got to look at individuals not following through with recommendations to spread the infection.”
Forecasting spread and hospital capacity
Models and forecasts of how coronavirus could impact communities often rely on a black-and-white scenario of doing nothing or doing something to mitigate the spread of the disease.
Or as Lofgren put it, “We’re cast in the role of predicting what happens to a house that catches on fire if no one calls the fire department.”
A stunning model from researchers at Imperial College in London, published March 16, did just that. Researchers predicted that if no mitigation strategies were put in place in the United States, 2.2 million people would die. When mitigation strategies were modeled, including case isolation, household quarantines and social distancing of elderly people, modelers estimated bed capacity still would be exceeded at local hospitals.
“In addition, even if all patients were able to be treated, we predict there would still be in the order of 250,000 deaths in GB (Great Britain), and 1.1-1.2 million in the US,” the paper says.
The paper, the Washington Post reported, influenced the Trump administration’s 15-day “Slow the Spread” campaign published last week, suggesting no gatherings of more than 10 people and extra precautions for those most at risk of developing severe disease.
Models and forecasts are simply that, however, and Lofgren cautions these models do not account for mitigation strategies that are nuanced: either schools are closed or they aren’t in a model, when myriad other options exist.
Similarly, models also do not account for any kind of change, like a drug being introduced to help treat patients and prevent deaths. Lofgren emphasized the Imperial model specifically looks at what could happen today, with or without intervention. Modeling for human behavior is difficult, therefore eliminating a lot of the potential nuance already at play in many community mitigation strategies.
As mortality rates and daily case numbers change rapidly with the ramping up of testing nationwide, other researchers have looked at a more immediate need: hospital capacity.
Harvard researchers published forecasts of how prepared hospitals would be depending on what percent of adults residents in each region in the United States were to contract COVID-19.
In a moderate scenario they modeled, where 40% of the population gets the virus over a 12-month period, the Spokane region would need to expand its hospital capacity, ProPublica reported. Intensive care units, the data show, would be particularly overwhelmed.
Local hospitals have been preparing to address these capacity issues by canceling elective surgeries, limiting or restricting visitation and designating specific care sites for people experiencing respiratory symptoms.
Current emergency department levels remain stable at Sacred Heart Medical Center, a hospital spokeswoman said in a statement, and the Providence-affiliated hospital has learned from its partners in Western Washington.
“We have begun to increase capacity to diagnose and treat patients throughout Spokane and Stevens County. We have learned a great deal from our colleagues on the west side of the state,” a Providence spokeswoman said in a statement. “Several of the steps we have taken were strategic to prevent a surge of patients coming to the emergency department.”
Providence has restricted all visitation at its hospitals, designated two sites for patients with respiratory symptoms and canceled all elective surgeries.
MultiCare, which includes Deaconess and Valley hospitals, has limited visitation to one person, in certain scenarios, designated two Rockwood clinics for respiratory patients and also canceled elective surgeries. Health care providers there are preparing to see an increase in patients.
“We are evaluating our hospital campuses to identify all opportunities to take care of more patients as we prepare. That includes looking at existing patient care spaces to see how we can use them differently,” a hospital spokesman said in a statement. “Through this work, we have determined that we could add many hospital beds across all our hospitals. We are working to procure the supplies and equipment including beds to do that.”
MultiCare also is preparing to use tents to expand their emergency departments, as well as developing plans to create open wards in their hospitals, in an effort to conserve masks, gowns and gloves.
As of March 18, Spokane hospitals have 1,100 beds, including 192 intensive care unit beds and 117 semi-intensive care unit beds, according to data reported to the Department of Health. Bed counts are really only part of the capacity picture, however.
Beth Zborowski, senior vice president at the Washington State Hospital Association, explains: “Those bed counts are staffed beds, and that’s kind of what we have all the time, but it’s not necessarily that they’re available. Hospitals aren’t built to have excess capacity.”
In other words, beds are not useful without the hospital’s ability to care for the patients in those beds. This is why hospitals statewide are cracking open their surge plans and beginning to create space to treat patients.
Zborowski said a major limiting factor for hospitals right now is getting or preserving the right supplies to treat a surge of patients with COVID-19. Inslee prohibited all elective procedures and non-emergent dental care last week to help preserve the statewide supply of personal protective equipment, which includes gloves, masks, face shields and gowns. He also announced Friday that large shipments from the federal stockpile are coming to Washington.
Providence launched a 100 Million Masks campaign in the Seattle area, sending materials to volunteers to sew masks, and all their materials have been sent out at this point. Protective gear in Eastern Washington remains at a premium, however, and rural hospitals are asking community businesses and members to donate masks they have in storage to health care workers.
Zborowski is also concerned about the ventilator supply.
“If we get a bunch more people that are very ill, we’re concerned about the supply of ventilators,” she said. “We need to get these resources here. We know this can be stopped, and we know what we’re lacking.”
Some Harvard researchers predict a spike in cases will overwhelm hospitals in the United States, despite preparations, based on the timing of the spread of coronavirus in other countries.
In Wuhan, where the virus originated, hospitalized cases spiked a month after the city shut down completely. In Guangzhou, where mitigation measures were implemented faster and more aggressively, hospitals saw a spike in COVID-19 cases two weeks later.
In both Chinese cities, the health care system did not see a spike in cases until at least a couple weeks after their mitigation strategies were in place. Applying this knowledge to the United States, the Harvard researchers warned, “Plans are urgently needed to mitigate the effect of COVID-19 outbreaks on the local health care system in U.S. cities.”
Rurals ramp up
Most hospitals are taking these forecasts seriously, including critical access hospitals in Eastern Washington.
Lincoln Hospital, in Davenport, already is planning for the possibility of taking some Spokane patients, if necessary. Carey Guhlke-Falk, communications director with Lincoln Hospital, said their leaders and health care providers are thinking about how to support the region’s medical community in the coming weeks.
“We need to do what we can to stay open so we are not only supporting our communities but also we are supporting the medical community in Spokane, too,” Guhlke-Falk said. “If we get to the point where we can’t stay open, that puts the burden on Spokane, too.”
Rural hospitals are struggling with supplies already, as they are running into the same supplier order backups as hospitals in the thick of surge capacity are facing.
“As of today, we have a shortage of supplies, so we are appealing to our business partners in our community to see if they have N95 masks,” Guhlke-Falk said last week.
Newport Hospital and Health Services is gearing up to treat COVID-19 patients and looking at re-opening their old long-term care unit. Christina Wagar, director of primary care at Newport Hospital, said they are preparing for the region to be saturated with the need for hospital beds, not just ICU beds.
“We are making plans to expand out how many patients we can care for. We are in the process of stocking up an alternative care site,” she said. “We expect to care for COVID-19 patients on site as this progresses because there may not be any place for them to go.”
Pullman Regional Hospital plans to open up a screening trailer for residents who are experiencing symptoms that have consulted with their health care provider first, starting next week.
Hospitals in Eastern Washington can collaborate and communicate with other hospitals to care for patients should cases become too severe or too numerous for one hospital to take on its own.
While many critical access hospitals have respiratory therapists, they might not have the ventilators necessary to treat a COVID-19 patient and might need to transfer a patient to a hospital that can provide that next level of care.
Testing is still a significant roadblock for rural hospitals, however, and despite an initial wave of expedited testing, rural hospitals reported that results can take up to a week to come back.
“When we have the inherent delays we are seeing – some test results we are seeing have been seven days from when test were taken to received – that really creates a difficult scenario from an isolation standpoint and identifying close contacts,” Matt Schanz, administrator at the Northeast Tri County Health District, said.
Currently there are 63 confirmed cases in 11 counties in Eastern Washington, with three deaths.
Rural health districts also have limited resources and staff to conduct contact investigations, which require epidemiologists.
The Spokane Regional Health District had four epidemiologists, and Lutz brought in two more last week to increase the district’s ability to track cases. Even still, many rural health districts do not have staff epidemiologists at all and rely on Spokane and other health partners to help conduct contact investigations.
Lutz acknowledged that eventually the district will not be able to conduct contact investigations on each case of COVID-19, though they will for clusters of the virus.
“Early on, yes, you start doing (contact investigations) because you are really trying to limit the spread and those PUIs (people under investigation) and the identified cases and their immediate contacts,” Lutz said.
Eventually, they will have to limit their efforts to outbreaks in community settings like nursing homes or schools where a large group could be at risk. Ultimately, he said, “it’s a resource issue.”
A ‘resilient community’
Limited resources have led governors and local health officers to continue to emphasize the importance of social distancing.
The efforts hospitals are making to prepare for more COVID-19 patients rely on the community mitigation efforts governors and local health officials have implemented.
And experts say avoiding respiratory-droplet contact with others and regular, thorough handwashing are key to slowing the spread of the disease.
Other societal mitigation strategies will likely continue to be updated and tweaked according to behavior. While Inslee did not order a shelter-in-place policy on Friday, like California’s Gov. Gavin Newsom did, he could still do so at any time.
Epidemiologists caution the public about the idea that coronavirus will die off in the spring. Harvard researchers who studied COVID-19 cases in different regions of China concluded that despite different humidity and temperature levels, weather alone will “not necessarily lead to declines in case counts without the implementation of extensive public health interventions.”
Of course, if mitigation strategies do work and virus’ spread slows, all the efforts underway might seem like an overreaction. But health officials and leaders are preparing for a surge in cases regardless.
“It’s out there. I think people need to understand that for the immediate future, just act like everybody has it. Social distance. Do your part,” Tom Wilbur, CEO at Newport Hospital, said. “Three months from now if we’re laughing at ourselves for overreacting, we’ll take that versus what it feels like we’re seeing (now).”
Meanwhile, local health officials are encouraging community members to take social distancing seriously and bolstering mitigation strategies. On Friday, Lutz closed jungle gyms and playgrounds to limit potential transmission of the virus by children.
“We are doing this in an effort to, again, ensure we are a healthy community and importantly a resilient community,” Lutz said Friday. “We will come back from this, and our lives will be changing in the next couple weeks and the next couple months, but the only way we can do this is collectively and collaboratively.”
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