Covid-19 is the name given to the novel Corona virus first discovered in Hubei Province, China. The new virus has since been defined and at the time of this article, is responsible for over 90,000 cases of respiratory illness and has spread to every know region of the World. The ultimate infection spread rate is still evolving but currently stands at 2-3 persons infected from every known contact and mortality rates are approximately 2-3%, while patients over 80 yrs. of age mortality rates are 15% thus far.
The WHO has activated strategic planning and is offering assistance under pandemic preparedness to countries most at risk due to poor medical infrastructure or lack of medical resources. The concern is not only wide spread disease due to exposure into high density, developing nations; but that this outbreak will burden medical systems beyond their capacity to provide services. This is a concern for both developed and underdeveloped nations.
This outbreak, approaching pandemic proportions, has created an urgent need for innovative solutions to reduce community spread and identify those most at risk or requiring treatment due to severe illness. It is at times such as this that innovators will have opportunity to create new solutions to deal with Covid-19 using the latest technology and tools. One tool of special importance would be virtual healthcare.
Virtual Healthcare is defined as any encounter between patient and provider for the exchange of information, treatment or diagnosis that is other than a face to face visit. This means providers engaging patients with secure electronic text messaging, phone calls or video calls if telemedicine platforms are available. Countries vary in their utilization rates for virtual care and a study by Kaiser Permanente in USA showed 60% of their patient encounters were virtual in 2017, while in Canada only about 0.3% of visits were classified as virtual. Now given the concern Covid-19 will place upon healthcare systems, virtual or video visits will be more important to protect front line healthcare staff and patients. Hospitals will need to attempt directing Covid-19 suspect cases away from their ERs and relie upon designated assessment centers to tightly control infection prevention protocols in the community. Patients requiring medical access for routine visits or non-urgent matters, can easily be handled using telemedicine during the peak outbreak season.
This article would propose a novel method of engagement using point of care testing, allocation to home based follow-up and potentially treatment with passive immune therapy that will likely be available before vaccines are created.
IDENTIFY CASES IN THE COMMUNITY USING POINT OF CARE TESTING
A South Korean company PCL, has Korean FDA approved rapid antigen test kits. These kits test for viral antigen using sputum from deep cough, or swabs from the nose and mouth. The sample is placed on a developer slide and after 10 minutes, using a UV light source, read as positive or negative. The kits currently listed at 25 USD per test, report sensitivity of 100% and specificity of 85%. The advantage is testing can be done easily in the community or in the patient’s home. This may allow regions to identify suspect patients by telephone triage and direct them to specific fever assessment centers or the kits may be dispatched direct to the home by community paramedics equipped with PPE.
TELEMEDICINE VISITS TO THE PATIENTS TESTING POSITIVE
The patients testing positive will require triage to remain at home for the current 14-day quarantine period established under WHO guidelines. Patients that are seriously ill can be transported to regional hospitals, should they require respiratory support, deeper investigation or monitoring. The patients dispatched home would be assigned to home temperature monitoring, and if available, could be visited virtually by community nurses or physicians. The complexity of the home-based monitoring would depend upon the infrastructure available. Developed nations are already providing remote patient monitoring with vital signs, blood pressure kits, oximeters and weight scales, with ability to connect live to nurses or physicians available on the platforms. The intent of the home-based monitoring is to detect progression of chronic disease states such as Congestive Heart Failure or Chronic Lung disease. These platforms can easily be converted to provide the supportive monitoring needed for Covid-19 that produces pneumonia and respiratory distress. Early signs of fever and a drop in oxygen levels would be an early indicator a patient may have progressed and would be allocated to supplemental oxygen and/or hospital admission. The goal of the community assessment programs and early identification of potential contacts, is to isolate as soon as possible so patients do not pass the virus to contacts within their community. A point of care triage system leveraging a kit such as PCL Covid-19 and telemedicine protocols for follow-up, will greatly reduce the numbers of patients coming to hospital ERs looking for assessments. As the volume of infections in a community increases, the risk of unknown or asymptomatic carriers infecting the Hospital OP or ER becomes greater. Local public health units could leverage community educations programs to help patients understand if they have a fever, cough and/or have been exposed to someone with Covid-19, they should contact the local health authority and NOT attend to the hospital or physician office. They would be instructed from home to be assessed by specialized teams of infection control officers or be sent to the local fever assessment center closest to them.
NOVEL TREATMENTS ON THE HORIZON
Companies are working fervently to create a vaccine for Covid-19. The challenge is knowing which part of the virus to target your vaccine against. This becomes an effort of complex bioengineering, modeling, and clinical trials on real world patients once a vaccine is in prototype form. Most experts believe a vaccine is at least one year away and the current rates of spread within some nations such as Iran, Italy and now South Korea, suggest wide spread disease much sooner than one year.
A company based in California called Bio Distributed, recently was featured in the Netflix documentary series called “Pandemic.” Dr Jake Glanville and Dr Sarah Ives have been working to create a single shot universal influenzae vaccine using their bioengineering protocols. Recently Dr Glanville and his team have now also focused on Covid-19. Dr Glanville believes that until an antigen vaccine is available, the other approach is to create a passive immunity vaccine. He believes it is possible to quickly replicate the antibodies our bodies make against Covid-19. Bio Distributed has a patented process that would allow bioengineers to build the antibody proteins first in the lab, then mass produce this antibody to fight viral infections already established in the patient’s body. This antibody can in injected or infused for patients tested positive that are acutely ill. Medical protocol and directives will be required to determine the optimal time of antibody infusion, and also determine which patients are at risk of serious illness or risk of death. Mass productions of the antibody and regional distribution may make this solution available only to more developed nations in the beginning but more than likely released to Countries experiencing widespread disease and perhaps priority for the regions with most serious outbreaks. This passive immunity would likely allow earlier discharge from hospital, freeing up needed beds and reducing healthcare infrastructure burden. Since the current infections seems to be targeting seniors over age 80, these efforts for passive immunizations might be focused on patients with complex needs or those at greatest risk.
This article is intended to stimulate discussion among leading authorities within the infectious disease community and hopefully create further collaboration on infection controls and treatments. The collision of ideas between innovators in various sectors of healthcare technology will be a fast track to solutions for the outbreak of Covid-19 and hopefully reduce the impact of what appears to be an evolving pandemic.
Dr Keith Thompson MD FCFP is Adjunct Faculty Dept Family Medicine at Schulich School of Medicine and Dentistry in London Ontario, Canada. He is Chief Medical Officer for iTelemed, a startup company providing virtual care solutions and involved in Virtual House call research and development.