Viewpoint: CDC’s Changing Guidance Underscores How COVID-19 Keeps Winning

Last week there were several revelations which caused grave concerns. The COVID-19 virus was found to be more infectious, more dangerous and at the same time healthcare workers and patient protections appear to have been relaxed.

Infectivity of a virus is measured by the R0 (pronounced R naught). This is the average number of individuals each infected person will infect. For the flu, this number is approximately 1.3. Initially, many were under the assumption that the COVID-19 virus was slightly more infectious than the flu. A few weeks ago it was described as 3 times as infectious, and last week the US Centers for Disease Control and Prevention (CDC) released a report that the R0 was equal to 5.7.¹At this level, over 80% of the population would have to be immune before herd immunity starts.²Part of the infectivity can be explained by the findings that under certain circumstances the virus can spread in aerosol form and spread with talking³and singing. The distance of spread from a sneeze has been estimated to be up to 27 feet.⁴

These observations compound the problems with asymptomatic spread, with 25% of COVID-19 positive patients being asymptomatic carriers and another group are presymptomatic carriers.⁴CDC Director Robert Redfield, MD, has stated that there are “individuals that may not have any symptoms that can contribute to transmission, and we have learned that in fact they do contribute to transmission.”⁵

There have also been a number of reports which indicate that the COVID-19 virus is not just a respiratory virus but can affect organs throughout the body. Researchers have found that 19.7% of those hospitalized had heart damage, and of those 51% died.⁶The virus can also affect the liver, kidneys, GI tract and central nervous system.⁷The latter can give rise to problems with the sense of smell and in some cases has even been postulated to decreased respiratory effort.

The CDC has replaced guidelines and issued emergency guidance for PPE use, extended use and limited use. The CDC’s recommendation of using a bandana as a last resort to stop the COVID-19 virus places our healthcare system at the level of a third-world country and underscores the severity of the current pandemic and erosion of our healthcare system’s infrastructure. Although cotton masks probably help in preventing transmission, questions have been raised regarding surgical and cotton masks effectively filtering SARS–CoV-2 during coughs by infected patients.⁸

The reusing of protective gear has erroneously been viewed as an “acceptable practice.” It is not, nor are facility practices of “only allowing use of N95s with confirmed COVID-19 patients, with few exceptions.”⁹Suspected patients need to be treated the same as confirmed patients.

In this backdrop of increased spread, known dangers and already relaxed regulations, the CDC has also outlined guidance for allowing COVID-19 confirmed or suspected healthcare workers to return to work.¹⁰I feel the non-test based criteria should be abandoned, since there are reports of asymptomatic patients having a positive COVID-19 RT-PCR after resolution of symptoms.¹¹Until the issue of viral reactivation in COVID-19, recovered patients can be clearly delineated,¹²recommendations for restriction of COVID-19 recovered healthcare workers’ contact with severely immunocompromised patients should be extended to all non-COVID-19 patients with high-risk comorbidities, including those with hypertension, heart disease, diabetes, cancer and over 60 years of age; and for an indefinite period of time. In addition, COVID-19 recovered healthcare workers should be tested at least weekly. Finally, the use of N95 masks needs to be specified.

The recent CDC recommendations are not intended for maximal safety, they may be necessary but only as a last-ditch effort to do the least harm where proper PPE is not available. There have already been reports of frontline staff sounding the alarm of contamination of patients and staff,¹³along with reports of wearing contaminated masks from patient to patient and reusing the same mask for 5 days.¹⁴Healthcare workers need to be properly informed of the risks to themselves, their families, and their patients along with being provided adequate healthcare and worker compensation benefits if they acquire COVID-19.

Needless to say, additional PPE is desperately needed, hopefully both increased manufacturing and sterilization techniques will relieve the shortage. In addition, the strategy adopted by New York State to designate some facilities to exclusively treat COVID-19 patients and others for non-COVID-19 patients to help improve patient safety should be adopted in other areas of the nation.

We must make protecting our frontline healthcare workers and patients a priority. Rapid testing will go a long way in assuring the safety of patients by identifying asymptomatic carriers in healthcare workers and staff.

References:

(1)  Sanche S, Lin YT, Xu C, et al. High Contagiousness and Rapid Spread of Severe Acute Respiratory Syndrome Coronavirus 2 .  Emerging Infectious Diseases.  Volume 26, Number 7-July 2020  https://wwwnc.cdc.gov/eid/article/26/7/20-0282_article

(2)  Helft L and Willingham E.  What is Herd Immunity?  NOVA.  Sept 5, 2014   https://www.pbs.org/wgbh/nova/article/herd-immunity/
  
(3)  How COVID-19 Spreads.  CDC.   https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/how-covid-spreads.html
  

(4)  Bourouiba L.  Turbulent Gas Clouds and Respiratory Pathogen Emissions Potential Implications for Reducing Transmission of COVID-19.  Jama Nework.  March 26, 2020.  https://jamanetwork.com/journals/jama/fullarticle/2763852
 
(5)    Whitehead S.  CDC Director On Models For The Months To Come: 'This Virus Is Going To Be With Us'.  CDC.  March 31, 2020.  https://www.npr.org/sections/health-shots/2020/03/31/824155179/cdc-director-on-models-for-the-months-to-come-this-virus-is-going-to-be-with-us
  
(6)  Shi S, Qin M and Shen B.  Association of Cardiac Injury With Mortality in Hospitalized Patients With COVID-19 in Wuhan, China.  Jama Cardiology.  March 25, 3030.  https://jamanetwork.com/journals/jamacardiology/fullarticle/2763524
  
(7)  Healy M.  Coronavirus infection may cause lasting damage throughout the body, doctors fear.  Los Angeles Times.  April 10, 2020.  https://www.latimes.com/science/story/2020-04-10/coronavirus-infection-can-do-lasting-damage-to-the-heart-liver
 
(8) Bae S, et al.  Effectiveness of Surgical and Cotton Masks in Blocking SARS–CoV-2: A Controlled Comparison in 4 Patients.  Annals of Internal Medicine.  April 6, 2020.  https://annals.org/aim/fullarticle/2764367/effectiveness-surgical-cotton-masks-blocking-sars-cov-2-controlled-comparison

(9)  Mencarini M., et al.    Hospitals 'burning through' PPE to fight the coronavirus turn to 'extreme measures.  Courier Journal.  March 28, 2020.   https://www.courier-journal.com/story/news/2020/03/28/coronavirus-hospitals-turn-extreme-measures-find-ppe/2925721001/

(10)  Criteria for Return to Work for Healthcare Personnel with Confirmed or Suspected COVID-19 (Interim Guidance).   CDC. https://www.cdc.gov/coronavirus/2019-ncov/hcp/return-to-work.html
  
(11)  Lan L, Xu D, Yu G.  Positive RT-PCR Test Results in Patients Recovered From COVID-19.  JAMA Network.  Feb. 27, 2020.   https://jamanetwork.com/journals/jama/fullarticle/2762452
    
(12)  Smith J. Cha S.  South Korea reports recovered coronavirus patients testing positive again.  Reuters. April 10, 2020.   https://www.reuters.com/article/us-health-coronavirus-southkorea/south-korea-reports-recovered-coronavirus-patients-testing-positive-again-idUSKCN21S15X   
  
(13)  Butler D.  Anguished nurses say Pennsylvania hospital risked infecting cancer patients, babies and staff with covid-19.  Washington Post.   April 11, 2020.  https://www.washingtonpost.com/health/2020/04/11/amid-chaos-anguished-nurses-say-pennsylvania-hospital-risked-infecting-cancer-patients-babies-staff/
    
(14)  Whitaker B.  Sick doctors, nurses and not enough equipment: NYC health care workers on the fight against the coronavirus.  Sixty Minutes.  April 12, 2020.    https://www.cbsnews.com/news/personal-protective-equipment-ppe-doctors-nurses-short-supply-60-minutes-2020-04-12/