What is making COVID-19 so difficult to contain? The fact that it is clearly spread by asymptomatic individuals, according to Paul Biddinger, MD, chief of the division of emergency preparedness and director of the Center for Disaster Medicine at Massachusetts General Hospital (MGH).

“It is spread by individuals before they begin to feel ill, which is a characteristic of influenza. That makes it much more difficult, and I would argue, impossible to control with public health measures directly,” he said during a March 13 webinar. “Once the disease is in the community, it really takes root.”

Consequently, Biddinger noted the United States has to focus on how to mitigate the impact of the outbreak, and make sure healthcare providers are in a position to deliver the best care possible for everyone who is infected.

“I don’t think it is possible to put the genie back in the bottle,” he lamented. “I think we are going to continue to see rising numbers of cases, but ... almost all of our efforts are focused [now] on blunting the epidemic curve, keeping the peak as low as possible because that peak is where the medical demand, the need for care, potentially exceeds capacity.”

That is where closing schools and businesses and implementing social distancing tactics come into play, according to Scott Gottlieb, MD, the former commissioner of the Food and Drug Administration, who also spoke during the March 13 webinar.

“You are not necessarily going to reduce the number of people who get infected over a period of time, although you may. What you are trying to do is keep the peak of the epidemic below the point at which the healthcare system gets exhausted,” he explained. “That is what happened in Hubei Province, China, and ... in Italy. The surge of patients came so fast that the healthcare system became exhausted and above the point at which it was able to adequately care for patients. You had a dramatic rise in deaths.”

In contrast, Gottlieb observed that South Korea put mitigation steps in place quickly, closing schools, transitioning people to telework, and canceling larger events. “That slowed transmission to the point where the healthcare system was able to adequately deal with the people who were presenting who were infected,” he observed.

Putting such mitigation steps in place can extend the length of the epidemic, but these measures also can reduce the chance there will be a sharp rise in cases. “The goal of mitigation is to take that peak and push down on it, flatten it out a little bit, and extend it out,” Gottlieb said. “The total time of the epidemic can actually get longer, but the number of cases at the peak is a smaller number.”

Gottlieb urged policymakers to adopt a more consistent approach to social distancing and mitigation steps. “You see an ad hoc approach among states and localities. Even among businesses, some states are being very aggressive ... and then some states haven’t been as aggressive,” he said. “We really need a more systematic approach, and we need to lean forward and be far more aggressive right now.”

To ease burdens on the healthcare system, Gottlieb is counseling hospitals to cancel all elective procedures and find ways to reduce volumes. “There are also probably administrative things that both the states and federal government could do to try to reduce some of the burdens on hospitals and put things off that aren’t going to adversely impact patient care in the near term while hospitals are focused on a much more difficult challenge right now,” he added.