Karen Hoffmann, RN, MS, CIC, FSHEA, FAPIC, a clinical instructor of infectious diseases at the University of North Carolina’s School of Medicine in Chapel Hill, recalls the near-panic and fear during the emergence of AIDS in the 1980s.

“With the COVID-19 outbreak in the U.S. population, it appears mixed messaging by media and federal agencies has led to a large percentage of the country not wanting to believe this is a real outbreak,” she says. “This resulted in a slow rate of compliance — or even open noncompliance — with social distancing and stay-at-home recommendations.”

A ‘Super-Spreader’

This is the result, in part, of a stealth aspect of the novel SARS-CoV-2 virus. It can spread from people who have mild illness or appear to be asymptomatic, yet still can cause severe disease and death in the elderly and those with underlying medical conditions. The Centers for Disease Control and Prevention (CDC) recently reported 16 COVID-19 cases that were transmitted in social gatherings.¹

“In this cluster, extended family gatherings, a birthday party, funeral, and church attendance, all of which occurred before major social distancing policies were implemented, might have facilitated transmission of SARS-CoV-2 beyond household contacts,” the CDC reported.

In an example of the “super-spreader” phenomenon, the index patient apparently was able to transmit infection to 10 other persons, despite having only mild symptoms that did not require medical care.

“Within three weeks after mild respiratory symptoms were noted in the index patient, 15 other persons were likely infected with SARS-CoV-2, including three who died,” the CDC reported.

Given the stealth nature of the virus and the considerable chaos that has accompanied its emergence, it is perhaps not surprising that some people find it counterintuitive that they actually are in a pandemic, even as it accelerates in the United States — the nation that now has the highest number of COVID-19 cases in the world.

There is even some level of complacency in healthcare workers in areas where there are few or no reported cases of COVID-19, says Hamad Husainy, DO, FACEP, an emergency physician at Helen Keller Hospital in Sheffield, AL.

“I will say in general for our staff, it hasn’t become as real as it has in other parts of the country,” Husainy says. “They seem to be a little complacent, and I hope when this is all said and done they can look at me and say, ‘You were wound a little too tight.’”

Given the lean stock of N95s, masks are worn over respirators that may be used indefinitely, he explained. “With regard to PPE [personal protective equipment] we really have not been well-prepared,” Husainy says. “We have literally two boxes of N95 masks in the entire hospital. We are being asked to take one and use it until further notice — until it gets visibly soiled or breaks or what have you. In dire circumstances, you do dire things.”

The hospital plans to use powered air purifying respirators (PAPR) — which can be cleaned and reused — in the emergency department if suspected coronavirus cases begin presenting.

“Right now, we are reserving them for the emergency medical staff,” he says. “In the ICU [intensive care unit], these patients have already been delineated as who is at risk and who is not. In the emergency room, people come in and you have to find that out. It’s a reality that we are going to run out of N95 respirators. My prediction is that our only option is going to be to use the PAPRs when we have to intubate somebody or place a patient on a ventilator.”

Husainy urges his coworkers to remain on guard, reminding them that some healthcare workers were infected before there was recognized transmission in the community.

In the early days of AIDS, a bloodborne disease, there were fears and speculation that it was spreading through the air or other means that were ultimately proven false. With no treatment, a diagnosis in those days was tantamount to a death sentence, and some healthcare workers died of needlesticks and other blood exposures.

“A large percentage of all staff were panicked to have to care for these patients,” Hoffman says. “When they did enter the room, some wore all the PPE they could find — head covers, double gloves, masks, and booties. Although there was initial concern of respiratory transmission, that was quickly ruled out. However, the fear to care for the known or suspected AIDS patients carried on for years.”

For the most part, healthcare personnel and the public have a healthy fear of COVID-19, but in some areas — exacerbated by mixed messages and a shortage of tests and PPE — the anxiety is at the early AIDS level.

“Certainly, this has been more extensive than anything I can remember in terms of epidemics and epidemics of anxiety,” says William Schaffner, MD, professor of preventive medicine at Vanderbilt University. I think the concern and the anxiety resembles the introduction of HIV [in 1981] more than anything else that I can remember.”

The Question of Immunity

Part of the fear and anxiety is being driven by the unknowns, including definitive evidence that those infected will become immune for some time period.

“That is certainly the hope,” Schaffner says. “If you look at the human coronaviruses — the ones that cause the common colds, you do get strain immunity — but it begins to wane fairly quickly after about a year. But that kind of immunity would be terribly important in blunting a resurgence of this virus in the fall. It might be a bridge to the time we can get a vaccine deployed.”

Anthony Fauci, MD, director of the National Institutes of Health National Institute of Allergy and Infectious Diseases, also recently commented on this issue in a live-streamed interview with the Journal of the American Medical Association.

“Right now, we don’t think that this [SARS-CoV-2] is mutating to the point of being very different,” Fauci said. “We are making a reasonable assumption that this virus is not changing very much. If you get infected in February and March — and then recover — that next September or October I believe that person is going to be protected. We are not 100% sure. But I think that is a reasonable assumption.”

Antibody tests are now coming on the market that could detect if someone has generated an immune response to a prior COVID-19 infection.

“There are a lot of companies trying to get them out, so they could be used for finger pricks with little devices and read within minutes,” Schaffner says. “This would be extraordinarily helpful in managing the healthcare and first responder environment. Then actually going out in communities and making an assessment about what proportion of the population is immune — it could help us get people with prior experience with the virus back to work.”

These tests certainly have great promise to affect the coronavirus response, but the antibody diagnostics must be validated carefully before they are distributed widely, Fauci emphasized.

“There have been international incidents where a country has ordered millions of these tests from another country — only to find that they don’t work,” he said. “We have to validate these tests — that’s absolutely critical, otherwise you will go down a path that will be very misleading.”

In some sense, public health has been a victim of its own success, with antibiotics, vaccines, and antiviral therapies creating the illusion that the U.S. healthcare system was ready for any threat, Fauci said.

“We let it slip, and boy, this should be a lesson for the future,” he said. “My hope is that when we get out of this — which we will — we will take a really good look at the long-term investments in the public health infrastructure. We should never again be in a position like this and have to scramble in response. This is historic. We all know the history of what happened in 1918, when we did not have hardly any of the interventions or the capabilities that we have now. You see what is happening in New York City, that is beyond sobering — that is really terrible.”

REFERENCE

1. Ghinai I, Woods S, Ritger KA, et al. Community transmission of SARS-CoV-2 at two family gatherings — Chicago, Illinois, February–March 2020. MMWR Morb Mortal Wkly Rep 2020; April 8. [Early release]. doi: http://dx.doi.org/10.15585/mmwr.mm6915e1