Two experts say we should prioritize those at risk from COVID-19 than to try to contain the uncontainable
Testing and tracking down contacts is ultimately futile for this virus, as it devotes enormous resources to finding cases that are largely mild and spontaneously resolving
By Dr. Neil Rau and Dr. Susan Richardson, NATIONAL POST March 15, 2020
A near empty United States check-in area at Toronto Pearson Airport’s Terminal 1 during concerns the Covid 19 virus, Friday March 13, 2020.
The early days of the COVID-19 were ominously reminiscent of SARS. We had a “mystery illness” originating in China with an animal market link caused by a virus with a genetic similarity to the SARS coronavirus. Not surprisingly, the WHO and the Chinese deployed the strategy that worked with SARS: find the cases with alacrity, isolate them, and monitor their immediate contacts for the development of disease.
Isolate the contacts if they get sick. The strategy worked: SARS was contained and it never returned. SARS, though it killed 10 percent of its victims, was not contagious enough to cause significant sustained community disease.But can COVID-19 really be contained? COVID-19 stopped following the SARS script weeks ago and appears similar to many respiratory viruses. COVID-19 along with the four “common cold” coronaviruses spread easily from person to person with mild disease, and sometimes from people before they develop symptoms. It is practically impossible to contain a virus that readily spreads early in the course of infection and circulates in the community.
The highest concentration and therefore transmissibility of COVID-19 in nasal secretions peaks in the first few days of infection. SARS was different: it was transmitted most efficiently late in infection. Therefore, using the SARS model to identify patients with the symptoms of COVID-19 is bound to fail. Moreover, it’s hard to pick out COVID-19 cases from those caused by other respiratory viruses also seen at this time of year. Testing and tracking down contacts is ultimately futile for this virus, as it devotes enormous resources to finding cases that are largely mild and spontaneously resolving.
COVID-19 stopped following the SARS script weeks ago and appears similar to many respiratory viruses
Now quarantine in its various forms, is being deployed as an ever-expanding strategy, from “self-isolation” to broad travel restrictions and school closures. This sledgehammer approach will affect mainly able-bodied workers, children and students, for whom a COVID-19 infection will be nothing more than a cold. It will put a huge segment of the workplace out of commission, including health care workers, at a time when we need them most.
The WHO containment ideal requires a huge societal sacrifice from those at low risk to prevent spread to those at high risk. Sacrifices include the avoidance of foreign travel (strangely this continues even after the disease is locally present) in addition to the cancellation of large events such as concerts, cultural events, sporting events and conferences. Tourism and service industries suffer. The stock market plummets. School closures are disruptive and costly to the parents who really cannot work from home. Higher education closures affect students’ abilities to complete or pay for their education if their exams don’t finish on time. Disinfecting surfaces at random in public places is resource intensive, costly and promotes a false sense of security.
We should instead be targeting significant resources toward the protection of those at highest risk (the elderly, those with underlying chronic disease, and those with immune compromising conditions) and maintaining a healthy, robust, responsive health care system that can handle a potential surge. The economic and social costs of pursuing quarantine are staggering and actually counter-productive.
COVID-19 shows no signs of slowing down yet and has finally been declared a pandemic by the WHO. While China’s outbreak wanes, multiple outbreaks are emerging around the globe. These outbreaks follow a similar pattern, i.e. initial cases are linked to travel or travel-related cases from known geographic areas of involvement, followed by rapid spread into the community without travel links. Cruise ship, nursing home and university campus outbreaks abound – SARS never did any of this. The WHO goal of stopping a respiratory virus which generates two to three new cases from each case has been compared with trying to stop the wind. The genie is out of the bottle.
Having failed to stop the virus completely, the WHO has revised the containment strategy to a novel one: to “flatten the outbreak curve.” This new strategy is being used to invoke severe restrictions to movement and liberty at an early phase of the pandemic in North America, although the effectiveness of this approach is unproven. Even China’s valiant efforts with unprecedented mass quarantine were only partly successful, and required a huge sacrifice of individual liberties. Great Britain is taking a more nuanced approach to containment, waiting to consider school closures and self-isolation of the elderly and other at-risk people, until the epidemic is on the upswing. They recognize that the goal of complete containment is not possible and that “containment fatigue” will result in failure to adhere to policies, if those measures are instituted too early and applied too broadly. We propose that WHO should abandon the containment ideal and urge countries to focus on how to best identify, prevent and treat infection in the population at risk of severe disease, in addition to protecting staff and patients in hospitals and the broader health care community. Once community disease is present locally, the vulnerable should avoid mass gatherings, and limit contact with visitors/family members who may unwittingly expose them to the virus. Nursing homes and hospital should limit, if not screen, visitors as well.
The head of the UN World Food Program now warns of absolute devastation as the COVID-19 effects ripple through Africa and the Middle East. Is this a direct consequence of the disease, or from the economic consequences of the WHO determination to contain it?
Dr. Neil Rau is an infectious diseases specialist and medical microbiologist in private practice in Oakville, Ont. He is also an assistant professor at the University of Toronto. Dr. Susan Richardson is a retired infectious diseases specialist and medical microbiologist. She headed the Ontario Laboratory Working Group for the Rapid Diagnosis of Emerging Infections during the 2003 SARS outbreak. She is a professor emerita at the University of Toronto.