Even as the Covid-19 outbreak has already overwhelmed some U.S. hospitals, in many cities anxious physicians feel more like coastal dwellers who learn that a tsunami has formed miles offshore: It hasn’t hit them yet, they know it’s going to, and they are desperate for information about how to survive it.
Now, fed up with what they see as inadequate and confusing directives from public health authorities, many physicians are trying to get on-the-ground advice directly from colleagues in countries that were the first to be hit by the coronavirus pandemic.
Hospitals in Baltimore, including those affiliated with the Johns Hopkins University School of Medicine, are coping, so far. Maryland’s case count rose from 190 on Saturday to 244 on Sunday to 288 by Monday night, however, mirroring where New York and other states were two weeks ago before Covid-19 began inundating their hospitals.
At Hopkins, physicians had been scanning scientific papers for clues to potential therapies and the use of protective equipment, said infectious disease physician Annie Antar, whose usual focus is HIV: “But our faculty had a lot of questions, so I thought, physicians in China dealt with this successfully.”
Early last week, she asked Weiwei Dai, a postdoctoral fellow in her lab who had graduated from medical school in China, for help. Hey, Antar said, can you connect me with any of your colleagues in China who had experience with Covid-19?
“All of my medical school classmates are clinicians in China now,” Dai said. “I quickly thought of people” who could help Hopkins understand what was coming and how to cope with it.
It came together within hours: They would have a Zoom meeting on Thursday, led by physician Jian’an Wang, president of the Second Affiliated Hospital of Zhejiang University School of Medicine in Hangzhou. It had sent 123 nurses, 42 physicians, and six other staffers to run an ICU in Wuhan, about 500 miles away, soon after the city was locked down in January. Although the number of new cases there and in surrounding Hubei province has dropped to the single digits (and, on some days, zero), many of the Zhejiang staff are still there.
“When facing a global crisis, sharing of medical and scientific information is invaluable if we are to save lives and halt the pandemic as quickly as possible,” said physician Paul Auwaerter, director of Hopkins’ division of infectious diseases.
A U.S. physician not involved in the Hopkins effort said that more and more of her colleagues are reaching out to those on the front lines in China, South Korea, and Italy for advice, especially as their doubts about guidance from U.S. authorities grow. The U.S. Centers for Disease Control and Prevention originally told physicians, nurses, and others caring for Covid-19 patients to use N95 masks, for instance, but earlier this month changed that to ordinary surgical masks for most needs.
Missouri nurse Rainee Sinroll was one of many U.S. health care workers who answered a STAT survey about their Covid-19 experience. This is “unlike any other outbreak I’ve ever been involved with. Absolutely NO training and info to staff that will be involved.”
The Zhejiang hospital was an obvious place for the Hopkins physicians to seek expert advice. Not only is it top-ranked in China for pulmonary medicine, intensive care, and other specialties, but it has more than 300 international trainees, most from the U.S. and Canada.
We want to work together with you to help fight Covid-19, Wang told the Americans as the hourlong meeting began. Their first question: If you were in our position, at the very beginning of the outbreak, what are the most important things to know?
The Zhejiang contingent took over one makeshift ICU in Wuhan on Feb. 14, plus one ward for Covid-19 patients in an existing hospital. They had 72 ICU patients, 55% older than 65, yet only nine of the ICU patients died; 17% required intubation in order to breathe, a procedure that risks making virus particles not only airborne but also aerosolized — meaning they can remain suspended in the air for some time.
The Hopkins doctors were keen to hear how their counterparts cured 35 intensive-care patients completely and brought the status of another 28 to only mild disease. With no surefire Covid-19 therapy and a blizzard of conflicting information on what existing drugs might work, Antar said, “one of our main questions was about their experience with off-label use” — repurposing existing drugs approved for other illnesses to use in the fight against Covid-19.
That experience has involved everything but the kitchen sink, though informed as much as possible by science. Several antivirals, including the HIV drugs lopinavir and ritonavir, did not accelerate recovery or reduce mortality, ICU physician Xiao Lu said. Some immune system regulators — including alpha interferon, anti-IL-6 monoclonal antibodies such as tocilizumab, and immunoglobulin — showed hints of efficacy in some critical cases.
Some patients received the malaria drug chloroquine, which President Trump has touted and which is being tested in a World Health Organization-supported clinical trial, but the Zhejiang team did not have rigorous data on its effects. They tried tocilizumab, too, a drug that has enough potential that on Monday, Genentech announced that it had received U.S. Food and Drug Administration approval for a clinical trial in Covid-19 patients with severe pneumonia; the rheumatoid arthritis drug, which goes by the brand name Actemra, might quell the out-of-control immune reaction that has killed many Covid-19 patients.
“All of us want to practice evidence-based medicine,” Antar said. “But the timeline for this might not allow us to wait for that.”
The right equipment helped. The Zhejiang team brought oxygen supply systems, monitors, ultrasounds, ventilators, and protective equipment from Hangzhou.
Who should be hospitalized, the Hopkins physicians asked? Suspected cases can be isolated and observed in their homes, they were told, as doctors in overwhelmed Italy are also telling U.S. doctors. Mild and moderate cases can be treated in mobile units, away from other patients; coronavirus spread within hospitals has been disastrous in Italy. Severe and critical cases in China get hospitalized, but at a dedicated facility, to reduce spread from Covid-19 patient to hospital worker to non-Covid-19 patient.
How do we know when a patient can be discharged, Antar and her colleagues asked? After a normal body temperature lasting three days, minimal respiratory symptoms, two negative tests for the virus more than 24 hours apart, improvements seen in lung imaging, and no serious underlying conditions, especially for older patients.
The Hopkins teams was impressed with China’s scrupulous measures to minimize viral transmission, “especially among health care workers,” Auwaerter said. “Such measures have successfully slowed the epidemic in China.” In contrast, failing to do so has fueled the disastrous spread of Covid-19 in Italy, physicians at a hospital in the country’s hard-hit north warned over the weekend.
The Wuhan hospitals “had a whole committee on PPE [personal protective equipment] adherence,” Antar said. “People would check if others were using it correctly. They’d work only four hours at a time so they wouldn’t become fatigued” and inadvertently dislodge goggles or other protection. “And they also had a committee to support the families of health care providers, including taking care of elderly parents and taking their children to school” in areas where those remained open.
Thousands of health care workers in China have become infected, though most of those cases occurred before stringent PPE practices kicked in. None of the Zhejiang contingent was infected.
As a result of the meeting, Hopkins’ infectious disease staff asked administrators to develop a plan, now, to set up, manage, and staff isolation units, Antar said, “pushing for measures that closely match what was done in China.”
While the Hopkins team is designing an evidence-based response, their Zhejiang colleagues ended the meeting Thursday by praying for the Americans.