Public Health Management of a Pandemic: A Primer for the Practicing Clinician
The figure depicts the potential impact of incremental social distancing, infographic courtesy of Robert A.J. Signer Ph.D., and Gary Warshaw, Art Director.
Our goal at K2P is to make a contribution to supporting all healthcare workers during this challenging time. To this end, we will continue to develop and maintain the timeliness of our comprehensive curriculum, and provide relevant insights from various thought leaders.
We will use this opportunity to highlight and make available relevant learning activities in our K2P library. Relevant content includes (1)topics on comorbidities like diabetes and hypertension that increase the risk of serious COVID-19 infection, and (2)topics that represent complications of COVID-19 infection including renal failure, adult respiratory distress syndrome (ARDS) and disseminated intravascular coagulation (DIC) and others.
We hope that you find our content and its organization into micro-units valuable at this critically busy time. Stay well and thank you for all you do.
What is the novel coronavirus?
- On January 7, 2020, China first reported that a cluster of pneumonia cases in people who had an association with a wholesale seafood market in Wuhan was due to a novel coronavirus, 2019-nCoV. Subsequent epidemiologic data indicated that person-to-person transmission of 2019-nCoV was occurring. Within 3 weeks, nearly 10,000 cases had been reported in over 20 countries. The first confirmed case in the United States was reported on January 20, 2020, in a Washington state resident who had recently visited family in Wuhan.
- Reports from the initial experience in China demonstrate that symptoms include cough (67%), fever (43.8% on admission and in 88.7% sometime during hospitalization), shortness of breath, headache, and myalgias. Complications include pneumonia, respiratory failure, acute respiratory distress syndrome, multi-system failure, and death. Based on what we now know about COVID-19 (and what is known about coronaviruses), transmission occurs person-to-person through respiratory droplets during close contact. For clinicians, this close contact may occur while caring for a COVID-19 infected patient by being within a proximity of 6 feet, and/or having direct contact with their infectious secretions (sputum, serum, blood, and respiratory droplets. The median incubation period is 4 days (interquartile range, 2 to 7).
What is different about this virus?
- Various viruses often strike one cohort more severely than others. The 1918 flu, which claimed 50 million lives worldwide, especially attacked young adults. The Zika outbreak (2015-2016) had a particularly devastating effect on pregnant women, affecting the brains of developing fetuses. COVID 19 infection appears to get more dangerous with age. Older adults have a higher risk of infection, a higher rate of hospitalization, and a higher case fatality rate. Although Americans > 65 represent 31% of the cases (in a report published in MMWR March 19, 2020), they disproportionately accounted for 45% of hospitalizations, 53% of ICU admissions, and 80% of deaths, the CDC reported.
- The inherent contagiousness of an infectious disease is measured by its basic reproduction number, or its R0 (R-naught). This number describes how many new infections an infectious person will generate in a population not previously exposed to the virus. An R0 < 1 indicates that a disease will die out, if R0 = 1, cases will remain stable, R0 > 1, the number of infected will grow. The RO of Covid-19 is estimated at 2.
For comparison, the R0 of measles is 12-18; the R0 of polio is 5-7. Various factors influence R0, including the duration of the communicable period and the mode of transmission. Clinical or public health interventions to reduce the number of susceptible hosts in a population (vaccination) or reduce opportunities for transmission (isolation, quarantine, and social distancing), can “flatten the curve” of the pandemic by reducing R0. Even without control measures or vaccines, R0 will eventually decline as those who survive infection become immune.
A social distancing lesson can be drawn from the 1918-1919 influenza epidemic. During the 1918-1919 influenza epidemic, US cities adopted a variety of public health interventions including school closure; cancellation of public gatherings; and isolation, and quarantine. There was a statistically significant association between early, sustained, and layered application of nonpharmaceutical interventions and mitigating the consequences of the 1918-1919 influenza pandemic in the United States.
The Three Core Functions and Ten Essential Services of Public Health
- Monitor health status to identify community health problems
- Diagnose and investigate health problems and health hazards in the community
- Inform, educate, and empower people about health issues
- Mobilize community partnerships to identify and solve health problems
- Develop policies and plans that support individual and community health efforts
- Enforce laws and regulations that protect health and ensure safety
- Link people to needed personal health services and assure the provision of health care when otherwise unavailable
- Assure competent public health and personal healthcare workforce
- Evaluate effectiveness, accessibility, and quality of personal and population-based health services
- Research for new insights and innovative solutions to health problems
The Organization of Governmental Public Health Agencies
US Dept of Health and Human Services (HHS) includes 11 agencies. The 5 described below are most involved in the management of the current pandemic.
Centers for Disease Control and Prevention (CDC) CDC Centers for Disease Control and Prevention: The CDC is the nation’s public health agency. Through its numerous health surveillance programs, the CDC detects and responds to new and emerging health threats. The CDC also translates the data collected into reliable health information to promote healthy and safe behaviors. The CDC collaborates closely with state and local health agencies on key public health concerns.
- Director: Robert R. Redfield, MD
NIH: The National Institutes of Health (NIH), a part of the U.S. Department of Health and Human Services, is the nation’s medical research agency Bethesda
- Director: Dr. Francis Collins
- One of the NIH divisions is the National Institute for Allergy and Infectious Diseases (NIAID), headed by Dr. Anthony Fauci
FDA: The Food and Drug Administration is responsible for protecting the public health by ensuring the safety, efficacy, and security of human and veterinary drugs, biological products, and medical devices; and by ensuring the safety of our nation’s food supply, cosmetics, and products that emit radiation. FDA also has responsibility for regulating the manufacturing, marketing, and distribution of tobacco products to protect the public health and to reduce tobacco use by minors. FDA is responsible for advancing the public health by helping to speed innovations that make medical products more effective, safer, and more affordable and by helping the public get the accurate, science-based information they need to use medical products and foods to maintain and improve their health. FDA also plays a significant role in the Nation’s counterterrorism capability. FDA fulfills this responsibility by ensuring the security of the food supply and by fostering development of medical products to respond to deliberate and naturally emerging public health threats.
- FDA Commissioner: Stephen Hahn, M.D.
US Public Health Services; Office of the Surgeon General: The U.S. Surgeon General is the Nation’s Doctor, providing Americans with the best scientific information available on how to improve their health and reduce the risk of illness and injury. The Surgeon General oversees the U.S. Public Health Service (USPHS) Commissioned Corps, a group of over 6,000 uniformed officers who are public health professionals. The USPHS mission is to protect, promote, and advance the health of our nation.
- Surgeon General: Jerome M. Adams, M.D., M.P.H.
The Health Resources and Services Administration (HRSA), an agency of the U.S. Department of Health and Human Services, is the primary federal agency for improving health care to people who are geographically isolated, economically or medically vulnerable.
- Director: Thomas Engels
STATE and LOCAL
The organization of governmental public health agencies at the state and local levels varies across the country. States are the primary authorities for public health. Federal policies influence but do not govern state and local public health practices. In addition to funding, CDC and other HHS agencies provide resources to state and local health departments, including consultative expertise, staff training, technical assistance, and related support tools. HHS agencies also support research and its dissemination that inform the scientific evidence base to guide public health practice.
States have autonomy defining their public health authority, determining the extent of government services provided and the way in which these services will be organized, financed, and delivered. State-local health department relationships may be centralized, decentralized or use a hybrid model.6
Many health departments have faced budget cuts, and key leadership positions are often part-time – including health commissioners and medical directors.
Suggested sources of accurate information that reflects the latest evidence