With 'Containment' Increasingly Infeasible, Physicians Offer a COVID-19 Mitigation Strategy


What does it look like when a health system switches from 'containment' to 'mitigation'?

As SARS-CoV-2 continues to spread around the world and rates of testing vary widely from state to state and country to country, a new article in the Journal of the American Medical Association argues public health officials need to shift from a “containment” mindset to a “mitigation” mindset.

Stephen M. Parodi, MD, and Vincent X. Liu, MD, MSc, both of Kaiser Permanente’s Permanente Medical Group, say a containment strategy becomes increasingly difficult as officials are less and less able to identify the sources of particular cases.

“When a small number of infected patients are in concentrated locales, containment strategies (ie, quarantine) can halt the spread of infection by isolating infected or exposed individuals from the general population,” they write.

Doing so, though, requires an all-hands, full-force approach of high numbers of health care workers using personal protective equipment and isolating patients in airborne isolation rooms.

Already, though, an inability to get an initial grasp of the situation has meant many health care workers have been exposed, requiring those workers to be quarantined and furloughed from their medical work. One major reason for that is the fact that some 80% of people infected with the virus show few or no symptoms.

Such a situation makes it exceedingly difficult to marshal the full-force containment approach, Parodi and Liu argue.

“As COVID-19 spreads both in the US and around the world, it may not be possible to care for all patients in this manner,” they note.

Instead, Parodi and Liu say, public health officials need to switch to a mitigation strategy.

They define the strategy as having five key features: slowing further spread of the virus; reducing the anticipated surge in healthcare use; providing adequate care to enable most patients to recover with only time-limited home isolation; expanding testing and hospital capacities; and tailoring isolation situations to limit the virus’ spread.

“Without rapid uptake of these approaches across hospitals, COVID-19 will pose a critical risk to an already strained health care system,” Parodi and Liu say.

The authors go on to outline the plan Kaiser Permanente has been developing to mitigate the virus’ impacts. They say the focus is to minimize transmission of the virus within the acute-care setting.

Since the virus appears to spread through droplets, Parodi and Liu said health care workers will protect themselves with surgical masks, disposable gowns, gloves, and protective eyewear.

“This approach is intended to simplify the workflow and preserve the use of enhanced airborne transmission precaution equipment like N95 masks and controlled or powered air-purifying respirators for patients with diseases like tuberculosis,” they say.

Additional protective equipment will be used in high-risk situations, and all single hospital rooms will be made available to accommodate droplet isolation.

The plan calls for patients with no symptoms or mild symptoms to be kept at home and treated via telemedicine to the extent possible.

Meanwhile, designated sites would be set up specifically for the evaluation and testing of patients with suspected cases of COVID-19.

For health care workers, the proposed plan calls for an approach similar to that used for influenza. If a worker is exposed to patients with suspected or confirmed COVID-19, they should self-monitor, Parodi and Liu write.

“If they become ill and are confirmed not to have COVID-19, personnel would remain off work until the resolution of fever and until their other symptoms begin to improve,” they say.

“Health care personnel with confirmed COVID-19 should be off work as per CDC guidelines.”

The authors conclude that they believe the strained health care system still has the ingenuity and skill to attain the upper hand against the virus, and they say consistent plans will be an important part of that process.

“Clear guidelines shared across hospitals and states could help improve the ability to maintain a capable and sustainable approach for all patients,” they say.

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