Am I part of the cure, or am I part of the disease

Monday 23th. March 2020 

Am I Part of the Cure or Am I Part of the Disease?
A colleague of mine Christian Rose from the Center for Primary Care and Outcomes Research, Stanford University, has written about, how health care workers are experiencing social stigma during the current outbreak of COVID-19.( https://www.nejm.org/doi/full/10.1056/NEJMp2004768?query=featured_home )¹ I believe that many health care workers in our health care system are having the same considerations during this period: We need to share and address these thoughts and worries, that we all have.

As Christian Rose puts it: “Times like this can leave physicians stranded between our commitment to the community and responsibility to our families — a no man’s land, where a colleague’s spare bed may be the closest approximation of home that we can find.”

The current testing situation
Last Friday it was announced that Denmark was close to running out of coronavirus testing kits. I am convinced that everyone can agree upon, that it is time to prioritize the testing. We need to assure a certain test activity, when the outbreak peaks. The Chinese had the same problem. They developed a clinical case definition and if patients fulfilled the criteria of the clinical case definition, no test was done.

Furthermore, the plan B is, that test analysis should be done via non-commercial in-house technologies. We are currently working hard to solve this.

Access to hydroxychloroquin
During the last couple of days, the use of and access to hydroxychloroquin has assiduously been debated in the Danish media. The facts are: No clinical documentation is available on the impact of hydroxychloroquine on COVID-19 infection. For further reading see Gao, J., Tian, Z., & Yang, X. (2020).² The Danish Pharmacy Board (Lægemiddelstyrelsen i Denmark) has now changed the group of medical professionals that can prescribe medicine containing the active substance hydroxychloroquine from B to NBS. This means that medicine containing hydroxychloroquine can only be prescribed by hospitals and medical specialists within rheumatology, dermatology and pediatricians. And no longer by general practitioners. The amending entered the 22th. of March 2020. A series of studies are currently investigating hydroxychloroquine impact on COVID-19.

The distinction between quarantine and isolation
The terms quarantine and isolation are being used often and interchangeably, but there is a difference. One definition is:

Quarantine
”In public health practice, “quarantine” refers to the separation of persons (or communities) who have been exposed to an infectious disease.

Isolation
“Isolation,” in contrast, applies to the separation of persons who are known to be infected.”³

Sources
1. Rose C. M. D. (2020). Am I Part of the Cure or Am I Part of the Disease? Keeping Coronavirus Out When a Doctor Comes Home. The Lancet. 2. Gao, J., Tian, Z., & Yang, X. (2020). Breakthrough: Chloroquine phosphate has shown apparent efficacy in treatment of COVID-19 associated pneumonia in clinical studies. Bioscience trends. 3. Parmet, W. E., & Sinha, M. S. (2020). Covid-19—The Law and Limits of Quarantine. New England Journal of Medicine.

Recommendations for further readings
• Gurwitz, D. (2020). Angiotensin receptor blockers as tentative SARS‐CoV‐2 therapeutics. Drug Development Research. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32129518

• Ramanathan, K., Antognini, D., Combes, A.,… et al. (2020). Planning and provision of ECMO services for severe ARDS during the COVID-19 pandemic and other outbreaks of emerging infectious diseases. The Lancet Respiratory Medicine. Available at: https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(20)30121-1/fulltext 

• Matthay, M., Aldric, J.M. & Gotts, JE. (2020). Treatment for severe acute respiratory distress syndrome from COVID-19. The Lancet Resporatory Medicine. Available at: https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(20)30127-2/fulltext

• M.N., Patel, J. & Parekh, D. (2020). COVID-19 and the liver: little cause for concern. The Lancet Gastroenterology & Hepatology. Available at: thelancet.com/journals/langas/article/PIIS2468-1253(20)30084-4/fulltext

• Nextstrain. (2020). Narrative: Genomic analysis of COVID-19 spread. Available at: https://nextstrain.org/narratives/ncov/sit-rep/2020-03-20?n=12

For the virological interested: The virological evolution (weekly updates). This week’s analysis includes 723 sequences isolates.

Quote: ”many places that have recently implemented social distancing measures can expect to see cases continue to accumulate in the short-term, but new cases will likely plateau and decline in the medium- to long-term.”

Figure: Adapted from: Nextstrain. (2020). Narrative: Genomic analysis of COVID-19 spread. Available at: https://nextstrain.org/narratives/ncov/sit-rep/2020-03-20?n=12