COVID-19: Learning rapidly from an overwhelmed healthcare system in Bergamo, Italy

A very sobering piece published in NEJM Catalyst Innovations in Care Delivery (a new digital journal in the NEJM group) describes a catastrophic situation in a hospital in Bergamo, Italy, which has been overrun by COVID-19. We all have much to learn from this experience: about pandemic preparedness, response, and the key role of IPC at all stages of this pandemic.

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COVID-19 – visualising the impact of social distancing

As we move through the gears of the response to the COVID-19 pandemic, the UK has entered lockdown – total social distancing. I’ve had many conversations with friends and family about what’s going on and why these extreme measures are necessary. I’ve pointed everybody who’s asked to the Imperial College London modelling, predicting a rapidly overwhelmed healthcare system if the trajectory of the UK epidemic doesn’t change. And pointed them in the direction of these rather cool visualisations of the logic behind social distancing (by cartoonist Toby Morris and microbiologist Siouxsie Wiles):

social distancing impact

COVID-19 and Q-fever: random observation or something to evaluate?

“The course of an epidemic is defined by a series of key factors, some of which are poorly understood at present for COVID-19” (Roy Anderson Lancet, March 9th)

While several of the factors are obvious and come to mind immediately, others, might at this point be speculation or indiscriminate observations that need further scientific evaluation.

One of the latter category, might be the observation I would like to share in this post. One of the regions of the Netherlands that presently has one of the highest COVID-19 rates, is a region in the South of the country. To our knowledge there is only one thing unusual about that region; About ten years ago, the region was in the midst of the Dutch Q-fever epidemic. Could one of those key factors that we don’t understand and that may lead to area’s with exceptional high rates of COVID-19 be previous infectious diseases such as Q-fever, or more general a higher prevalence of previous long damage, due to infectious diseases? 

Have a look at the graphs and please share your thoughts.

With thanks to my colleague Bert Mulder, Nijmegen

COVID-19: hello social distancing

The UK government yesterday announced a far-reaching package of social distancing measures to suppress the spread of COVID-19. These are based on some Imperial College London modelling work, published here. The model predicts that the UK approach to mitigate the impact of the UK epidemic would indeed reduce the overall number of people affected and those who die, but would still leave hundreds of thousands dead in an overwhelmed healthcare system. In contrast, a more intensive suppression approach would be effective in reversing the epidemic trend and keep the number of new cases to a low level – in the short term, at least.

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Considering the role of environmental contamination in the spread of COVID-19

We know that respiratory viruses can be spread through droplets, occasionally aerosols, and contact routes (see Figure 1). But what is the relative importance of these transmission routes for the SARS-CoV-2 virus, which causes COVID-19? A new pre-print paper published yesterday provides evidence that the stability of the SARS-CoV-2 coronavirus is broadly comparable to the ‘original’ SARS coronavirus (SARS-CoV-1) on dry surfaces and in aerosols. This paper supports an important role for dry surface contamination and aerosols in the spread of SARS-CoV-2, and suggests that improved environmental persistence isn’t the key to the relative success of SARS-CoV-2 over SARS-CoV-1.

Figure 1: Transmission routes of respiratory viruses (from this review article).

covid transmission routes

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COVID-19 and my idea on masks

Next to the idea that we see many contraptions (you can’t even call them masks) we see many people with all kind of masks, in and outside our healthcare settings. Certainly after my last flight to a WHO meeting on COVID-19, I had the feeling that it is time to write about masks.

On my way to Geneva, the gentleman to my left (yes, thanks to a canceled flight, I was in the hated middle seat) was calm, sleepy and wearing a mask. The fellow on my right, clearly had the sniffles, came from somewhere far away and was spreading his respiratory secretions in all directions, including mine. I so wanted to pull of the mask from calm-sleepy-guy, to place it on the next-seat-germ-blower.

How easy could basic prevention be? Wouldn’t it be fantastic if people would adhere to simple principles of how to cough and sneeze in public: turn away from others, use a tissue or elbow, followed by hand hygiene? Why don’t the people on buses, trains and airplanes don’t know this? If in addition, anyone who is sick gets a surgical mask while in public, we might have a way of preventing (or at least delaying) the spread of respiratory viruses. Instead, masks are worn by the healthy, leaving the sick (and soon-to-be hospital patients) without the needed protection.

Talking about masks in healthcare; Nearly every country I know off, went for maximum safety, recommending FFP2 masks (similar to N95). I would have suggested to use FFP1 for the majority of cases, and FFP2 only during high-risk procedures. But how can I, if everyone else seems to go “full safety”. Another reason, why I believe that my idea wouldn’t have been too bad, is the high probability that soon we will have a shortage of FFP2 and will have to tell our HCWs that FFP1 and surgical masks are “equally save”. Yes, I can see how they believe me and willingly expose themselves to the increasing number of patients with less than previously needed PPE! I believe that we have valid reasons to consider evidence over maximum safety, and that while we didn’t even start to talk about discomfort and physical effects associated with prolonged use of FFP2. Continue reading