On: COVID-19 FAQ

Episode: 98

Date: March 2020

Background: Internal medicine physician and co-author of Genius Foods.

Key Subjects:

• Impact of limited healthcare capacity.
  • Lack of ICU beds drives higher morbidity rate of COVID-19.
    • Inability to provide appropriate care for those hospitalized.
  • NY State example:
    • About 3,000 ICU beds.
    • COVID-19 alone will fill ICU capacity in about 3 weeks.
• Typical pathology of COVID-19.
  • Virus uses ACE2 receptor for entry to infect lung cells.
    • ACE2 receptors found throughout the body.
    • Also in kidney, heart, blood vessels, etc.
  • In the lungs, replication of the virus damages the alveoli.
    • Alveoli are particularly prone to infection.
    • Particularly high level of ACE2 expression.
  • Damage to alveoli causes the lungs to fill with fluid and collapse.
    • Acute respiratory distress syndrome (ARDS).
  • Mechanical ventilation needed for up to 5 weeks.
• Unclear at this point which existing drugs can be used for treatment.
  • Remdesvir (Ebola) and others being explored.
• Collective strategies to lower impact of COVID-19: 
  • Lowering the rate of transmission:
    • Decreased social interaction.
    • Testing (identify).
    • Appropriate triage system (isolate).
  • Lowering the fatality rate: flatten the curve, buy time.
    • Flatten the curve to lower strain on hospitals:
      • Reducing transmission -> lower strain -> improve morbidity rate.
    • Buy time to develop new drugs:
      • Re-purpose existing drugs.
      • Lower healthcare worker infection.
      • Build (ICU) capacity.
• Individual strategies:
  • Sufficient sleep, moderate (zone 2) exercise, self-quarantine as needed / appropriate.

Comments

• It is becoming increasingly clear that the hospital capacity of many Western countries is insufficient to handle the peak surge associated with COVID-19. 
• Strategies to lower the strain on hospital capacity by lowering the rate of transmission are sometimes labeled “flattening the curve” or “containment”. It’s not always clear what is meant by either term. 
• In some corners, it is argued that especially the “flattening the curve” language and associated simple graphics underestimate the enormous amount of effort required (above and beyond washing hands, protecting the elderly, etc.) in some places to lower the rate of transmission to the point that it would materially reduce the strain on hospital capacity given the existing levels of cases. 
• As convincingly argued by this article, in places where COVID-19 has already spread for 2-3 weeks, a switch towards more drastic measures such as collective lock-downs will likely be needed in order to avoid overwhelming demands on healthcare capacity.