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Thursday, March 26, 2020

ANALYSIS/OPINION:

Evidence-based, rational public policy is urgently needed, now more than ever, as the contagion of fear spreads far faster than the coronavirus COVID-19. The harms from continuing widespread isolation and this economic lockdown, including actual loss of life, could be enormous, far greater and longer lasting than from coronavirus infection itself.

Two important points need to be understood: 1) targeted isolation is correct policy in terms of medical science, not just economically; and 2) testing is important but it should be prioritized, instead of thought of as urgent for everyone.


Dr. John Ioannidis, an epidemiologist and co-director of Stanford University’s Meta-Research Innovation Center, stated that reported case fatality rates, like the official 3.4% rate from the World Health Organization, induce panic but are “virtually meaningless”. Patients who have been tested for coronavirus and seek medical attention are disproportionately those with severe symptoms and bad outcomes.

Dr. Ioannidis estimates the fatality rate in the general U.S. population to be from 0.05% to 1% based on the Diamond Princess cruise ship, the one closed and completely tested population. Importantly, the fatality rate in that group was 1.0% in a largely elderly population (approximately 60% over age 60), in which the death rate as well as infection from Covid-19 is much higher (note that approximately 75% of confirmed infections on that ship were over age 60).

This is similar to the more widely tested South Korea population (approximately 1% fatality). Among developed countries so far, the death rate is just over 1%. In developed countries (OECD), there are approximately 17 endemic viruses. Worldwide, about 2.6 million deaths occur from these per year. In the United States, deaths from the flu range from 30,000 to 45,000 in the United States.

There is massive uncertainty, but using Ioannidis’ mid-range fatality rate, this virus could cause about 10,000 deaths in the United States overall, overall, a number that would not be extraordinary news in the total of flu-like deaths every season. 

Dr. David Katz, the director of Yale’s Disease Prevention Center, wrote in The New York Times that the clustering of deaths and serious diseases in the elderly and those with significant chronic illnesses indicates we could and should preferentially protect those vulnerable populations. This would accomplish the goals of saving lives, avoiding the overwhelming of the medical system, allowing the essential immunity to develop among the population with virtually no risk of serious illnesses, and avoiding the massive economic calamity and all that would entail.

There is a different strategy, one focused on protecting the vulnerable, self-isolating the mildly sick, and limiting group interactions, similar to recommendations in the Netherlands. And the data so far show no worse spread than nearby countries like Germany, Belgium and France with far stricter lock-downs in place.

First, medical care must be sought by some, but it is not necessary for the majority of people who are infected. If a person, particularly the elderly, has underlying chronic lung disease, heart failure, kidney failure, or diabetes, and has a fever and respiratory symptoms like cough or shortness of breath, they should seek medical attention. These are the people who have a significant risk of progressing to severe illness, as reported all over the world and in the United States.

We know that up to 99% of positive cases have nothing beyond mild symptoms. A University of Oxford study estimated that fewer than 0.1% of infected cases have significant symptoms requiring medical care. Younger, otherwise healthy people with mild symptoms should not go to the hospital or seek medical attention, because treatment is not necessary and it will overwhelm the system while potentially infecting health care providers and patients.

These patients should stay home and isolate and get tested when it’s available - unless they develop shortness of breath or a fever above 38’C, (100.4F) for which they should seek care.

Second, isolation is key, but it must be targeted for specific groups of people. If someone outside the high-risk groups (elderly with chronic illnesses, HIV patients, immune-compromised people) has fever and cough but mild symptoms, they should remain isolated in their homes for 14 days. People without any symptoms who have not been directly exposed to someone sick do not need isolation.

More importantly, whole-population isolation is not medically ideal and will lead to less effective elimination of the infection threat. Population immunity for every disease like this can only be achieved by letting people who are not at risk for anything serious, who are not immune-compromised and elderly (the vast majority of people), get exposed to it.

This allows their bodies to put forth the immune response, so the virus is controlled and transmission to others is eliminated. That’s biology — not politics, not economics, and not non-medical risk assessment. We are preventing the development of immunity that is essential to stop the illness, and prevent a second wave when people are free to mingle. 

Third, testing is important, but right now, it is a priority only for certain groups of people. As recommended this week by the Infectious Diseases Society of America, testing for COVID-19 should be prioritized as follows:

Tier 1 — the highest priority — critically ill patients receiving ICU level care with unexplained viral pneumonia or respiratory failure; patients with fever and respiratory symptoms within 14 days exposure to proven coronavirus patients; immunocompromised patients (elderly with chronic illnesses, HIV patients, etc.) with fever and respiratory symptoms; and people with fever and respiratory symptoms who are critical pandemic response workers.

Tier 2 testing — another high priority — should be for hospitalized (non-ICU) patients and long-term care residents with fever and a respiratory tract illness. Fear of exposure, or people without symptoms who are outside priority groups, do not need urgent testing and should not seek it.

Strategic prioritization of testing, isolation, and medical care, with factual communication rather than worst-case scenarios extrapolating from misleading data are urgently needed to save the national interests and livelihoods of Americans.

To continue the current policy without targeting will unnecessarily overwhelm our medical system and literally endanger patients needing care and our health care providers. And to isolate the entire population and prevent all human interaction is actually harmful to eradicating the disease. We the people, including our leaders and policymakers, need to listen to the facts.

• Scott W. Atlas, MD is the David and Joan Traitel Senior Fellow at Stanford University’s Hoover Institution, the former chief of neuroradiology at Stanford University Medical Center, and the author of “Restoring Quality Health Care: A Six Point Plan for Comprehensive Reform at Lower Cost.”


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