Editorial
Message from the Editor-in-Chief
The Next Phase in the Management of the
COVID-19 Pandemic: A Discussion of Trade-Offs of
Different Strategies
The first phase in managing the coronavirus pandemic has largely omitted
a discussion of trade-offs of different pandemic management strategies,
and rightly so. The strategy enacted by our government leaders under the
advisement of public health professionals has been largely unidirectional: to
impose widespread – even by wartime standards – societal restrictions that
severely limit human-to-human contact while accepting the associated, and
in many areas devastating, economic consequences. The target endpoint
has been clear: to mitigate infection spread and allow time for health care
institutions and systems to prepare for immediate and future “surges
of coronavirus-related infection and hospitalizations. Our society and
profession have responded admirably in adhering to these restrictions
and in achieving the desired endpoint.
The next phase in managing the pandemic warrants candid, bidirectional
discussions of the trade-offs of a broader versus targeted strategy for
restrictions to in-person interactions. This discussion is needed because the
next endpoint, that is the availability of a coronavirus vaccine, is at least 12
months away from now, probably 24 months away, and possibly longer.
1–3
Healthcare professionals can have a pivotal role in this discussion
and debate due to the tremendous influence they currently wield to advise
institutions and governments on policy decisions. As general internists,
we frequently deal with trade-offs when deciding about the benefits and
risks of a diagnostic test, an intervention or a treatment; these trade-offs
consider NNTs versus NNHs, the impact of events prevented versus caused,
QUALYs gained versus costs incurred, all alongside patient-centric values
and preferences. Engagement by healthcare professionals can occur at a
broader level with public health professionals or governments (federal and
provincial) for discussions as to the long-term economic consequences of
broader versus targeted restrictions to in-person interactions. Closer to
home, we can engage our local institutions or provincial governments to
discuss and debate trade-offs to managing the next phase of the pandemic;
this can occur in at least two areas.
The first is to consider the trade-offs of virtual versus in-person
medical care. It can be argued that although virtual care is not new and
will continue in an expanded capacity, it should not routinely replace the
meticulous attention to detail, personal engagement, and the humanity that
can only be fully provided through in-person (but protected
4
) encounters.
In terms of balancing risks, this should consider the risks of infection
spread in a protected in-person environment against the putatively higher
risks of harm or deterioration of health status to patients with a virtual
visit-focused approach. It is important to acknowledge that COVID-19 has
disproportionately devastating effects on the elderly, especially those who
reside in long-term care facilities: overall infection fatality rates of 10.7%
in those 60–79 years old, and 31.4% in those >80 years old
5
– though these
fatality rates are likely much lower in persons without comorbidities.
6
These
vulnerable groups need meticulous protection during in-person health
assessments.
4
On the other hand, we are starting to uncover the collateral
health consequences of societal isolation and limits on in-person access
to health care, which include higher than expected rates of cardiovascular
events and overall mortality, even after accounting for COVID-19 deaths.
7,8
The second is to consider the trade-offs of virtual versus in-person
learning. Herein, it can be argued that we need to get our students and
learners – children, adolescents, young adults – back to school and in the
clinical environment ASAP, meaning in September 2020. For this issue,
the trade-offs appear more one-sided: the associated benefits of allowing
learners to return to school are likely to outweigh the harms done through
continued remote schooling and learning for the next 12 to 24 months. In
terms of balancing risks of in-person versus virtual learning, COVID-19
appears to disproportionately spare young people: overall infection fatality
rates of 0.06% in those <19 years old, and 0.11% in those 20–39 years old
5
though these fatality rates are likely lower in persons without comorbidities.
6
An in-person strategy will come with caveats so that vulnerable contacts
are protected. Students in schools will benefit from in-person interactions
with their peers and teachers to develop essential socialization and learning
skills. Learners in the medical field will reap immeasurable benefits from
having (protected) in-person encounters with patients.
There will be counter-arguments and criticisms to such bidirectional,
trade-off-based discussions – this is welcome and needed. For example, it
might be argued that although coronavirus-related fatalities in otherwise
healthy young people are very rare, we are uncertain about long-term
infection-related morbidity. Admittedly, an assessment of trade-offs will
accept some uncertainty but this goes both ways: we are also uncertain
about the negative consequences of long-term remote learning. There is
also the overarching uncertainty that a vaccine, if available in 12 to 24
months, will be sufficiently effective to prevent infection.
In the coming days and weeks, medical professionals can have an
important role to discuss and debate different strategies and trade-offs in
managing the next phase of the pandemic. Let us engage in this discussion
in a vigorous, bidirectional, and candid manner to achieve a balanced
way forward.
References
1. Graham BS. Rapid COVID-19 vaccine development. Science 2020;368:945-6.
doi: 10.1126/science.abb8923. Epub 2020 May 8.
2. Lurie N, Saville M, Hatchett R, et al. Developing COVID-19 vaccines
at pandemic speed. N Engl J Med 2020;382:1969–73. doi: 10.1056/
NEJMp2005630. Epub 2020 Mar 30.
3. Hanney SR, Wooding S, Sussex J, et al. From COVID-19 research to vaccine
application: why might it take 17 months not 17 years and what are the wider
lessons? Health Res Policy Syst 2020;18:61. doi: 10.1186/s12961-020-00571-3.
4. Chu DK, Akl EA, Duda S, et al. Physical distancing, face masks, and eye
protection to prevent person-to-person transmission of SARS-CoV-2 and
COVID-19: a systematic review and meta-analysis. Lancet 2020;395:1973–87.
doi: 10.1016/S0140-6736(20)31142-9.
5. Public Health Ontario. Daily Epidemiologic Summary. [Internet]. Available
at: https://files.ontario.ca/moh-covid-19-report-en-2020-06-28.pdf
6. Erikstrup C, Hother CE, Pedersen OBV, et al. Estimation of SARS-CoV-2
infection fatality rate by real-time antibody screening of blood donors. Clin
Infect Dis 2020 Jun 25:ciaa849. doi: 10.1093/cid/ciaa849.
7. Weinberger DM, Chen J, Cohen T, et al. Estimation of excess deaths
associated with the COVID-19 pandemic in the United States, March to
May2020. JAMA Intern Med 2020; doi:10.1001/jamainternmed.2020.3391.
8. Woolf SH, Chapman DA, Sabo RT, et al. Excess deaths from COVID-19 and
other causes, March-April 2020. JAMA 2020. doi:10.1001/jama.2020.11787.
James Douketis MD
Editor-in-Chief
Canadian Journal of General Internal Medicine
Canadian Journal of General Internal Medicine
4 Volume 15, Issue 3, 2020
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