Increasing Hospital Capacity

Australia has an opportunity to learn from what is happening in Italy as that is likely to be us in one month. One hopes that the Government and health departments understand the impact of the disease on hospitals

Once the demand soars for hospital services, a number of things will need consideration.

  • can we keep corona and non-corona cases separate ?
  • how can we optimize the use of whatever resources we have here to manage the care of patients.

In Australia we have a private and public system and this means that taken as a whole, our system has much more excess capacity than a purely public system such as France or Italy. Negotiating fair terms with the owners of those facilities is best done before the crisis hits. The Covid-19 cases in Italy requiring hospitalization have generally needed high level care; many intensive care and have had long hospital stays

To properly understand hospitals, it is important to understand equipment and staffing. A typical surgical or medical ward looks like this

although this ward is empty, there is capability for some simple monitoring (such as pulse and oxygenation, maybe blood pressure) some oxygen supplementation and an infusion or two. A nurse may look after 4 patients

Contrast this with ICU

taken from http://crystalandskyler.blogspot.com/2010/09/these-are-all-machines-that-are.html

In this example there are syringe driver pumps, infusion lines, a ventilator, a dialysis machine and many monitors. A general ward cannot do the same function. ICU will have one to one nursing.

This report https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0020/473330/ACI-ICU-Exit-Block-Guiding-Principles-Consultation-draft-January-2019.pdf

shows that NSW ICU occupancy is already at 90% in the winter months. Although cancelling all elective surgery would free up significant numbers of beds in ICU it would likely only increase availability by 20%. Around 40% of ICU admissions come post surgery but much of that surgery would be emergency

It may be possible to convert private hospital recovery

or operating theatres

Image result for operating theatre

into makeshift ICU or high dependency beds (as is being done in Italy) but this will require negotiation with private hospital operators and importantly will require large numbers of staff to be recruited / redeployed / upskilled

The time to plan for this is now.

Getting retired doctors back to work

One of the ideas to address a likely forthcoming workforce crisis is that of getting retired doctors back to work. The Victorian manifestation of this idea is not novel. Boris Johnson floated the same idea in the UK

https://www.theguardian.com/society/2020/mar/10/government-fails-to-detail-how-retired-doctors-plan-will-work-for-coronavirus

It is not a simple task. Maintaining medical registration has become more complex and costly in the last 2 decades.

Once upon a time, doctors could maintain a sort of inactive registration through which they could retain prescribing and referral rights. This was removed in 2003

https://www.news.com.au/lifestyle/health/exclusive-retired-doctors-to-lose-script-rights/news-story/bc43210c8ca7545249aee87b51ed9352

The State and Commonwealth Governments now have no easy way to contact let alone recruit these practitioners. The roadblocks to them working again include

  • No current registration and no easy and quick method to re-verify and re-credential original training
  • Current standards do not allow doctors out of practice for more than 12 months to practice without an approved plan http://cybersecurity.sarossy.com/medical-recency-of-practice-registration-standard/
  • Medical practitioners need by law to participate in Continuous Professional Development. These programs are administered by the relevant colleges. It is near certain that retired doctors would have allowed these memberships to lapse as membership is very expensive
  • Doctors who have retired and triggered the Run Off Cover indemnity scheme find it very costly and difficult to regain indemnity insurance

In short, although it is possible to re-recruit retired doctors to the workforce, it is something that requires careful thought and planning and involvement of many departments and organisations.

If it is a serious suggestion, the time to enact it is now.

How Governments should Respond

Covid-19 will pose severe challenges to society in 2020. These will include

  • Health services – these could easily get overwhelmed
  • Workforce shortages – we will feel the lack of employees in some industries very acutely eg health, docks, truck drivers, people maintaining utilities etc
  • Law and Order
  • Economy – some sectors will be devastated – we will need a plan to get them back
  • Supply chain – we may need to re-establish certain manufacturing here

It appears that we have more time to prepare than Italy or South Korea but it is important to use the time carefully. We should also learn from history.

An analysis of the response (suboptimal) to the Spanish Flu is here

https://www.phrp.com.au/wp-content/uploads/2014/10/NB06025.pdf

An analysis of the response to the Mississippi flood of 1927 is here

https://historynewsnetwork.org/article/17255

and was generally but not universally considered to be good.

At this stage of the crisis, consideration should be given to naming an individual to be in charge of the planning and response and to start to create the framework for the crisis response.

Economic intervention from Government will be needed. A rush to simplistic measures such as interest rates cuts and cash vouchers should be avoided

Testing Virus survival

There are a large number of claims about how the virus that causes covid-19 : the SARS-CoV-2 virus can or cannot survive under certain conditions

For example, can it survive in the sun, on metal, in water etc

Unlike testing for the presence of the virus – which is done with detection of viral RNA, testing for the viability of virus is very much more difficult. Most of the claims – if based on fact at all -are extrapolation from what is known for poliovirus – the standard test virus

To test SARS-CoV-2, it is necessary to culture the virus. consider the question “can the virus survive in swimming pool water?”

To test this we would put a known quantity of virus into standard swimming pool water, and then at some later stage attempt to grow the virus in a cell culture. It can be grown in the Vero-E6 line

https://www.protocols.io/view/culture-of-the-severe-acute-respiratory-syndrome-c-bcduis6w

and it is easy to see which cells have been killed by the virus.

Such sorts of tests need to be undertaken in a highly secure lab – so the virus cannot get out. Australia has only 3 such PC4 (Physical containment labs)

https://apps.who.int/iris/bitstream/handle/10665/311625/WHO-WHE-CPI-2018.40-eng.pdf

China has a few too – one in Wuhan

Developing a Vaccine

It is hoped that a vaccine can be developed for the virus quickly. That may not be so easy

There are some early results suggesting that antibodies to the spike protein of the virus have some promise in protecting cells against infection. Translating this into a vaccine which is safe to administer to millions of healthy people will not be quick

https://www.theverge.com/2020/2/28/21156385/covid-coronavirus-vaccine-treatment-moderna-remdesivir-research

Development of any pharmaceutical needs careful development. Progress occurs through phase 1 (safety) studies, through phase 2 and 3 (efficacy) studies. Research to refine the target population and the optimum dose is required.

Rushing such a thing can lead to problems. It is widely thought that immunization for the “swine flu” in 1976 caused an outbreak of Guillain-Barre´ s syndrome. There were issues with the testing and manufacture in response to the pandemic

https://academic.oup.com/jid/article-pdf/176/Supplement_1/S69/2797707/176-Supplement_1-S69.pdf

That can be contrasted with the careful development of the Gardasil vaccine

http://www.hu.ufsc.br/projeto_hpv/Safety,%20immunogenicity,%20and%20effi%20cacy%20of%20quadrivalent%20human.pdf

which took years of development.

Potentially life saving experimental treatment for desperately unwell patients with no other options is one thing. Giving inadequately tested vaccine to healthy people is another entirely

The diagnostic test

The gold-standard test for Covid-19 is qRT-PCR. This stands for quantitative, reverse transcriptase polymerase chain reaction. In essence this converts viral RNA to DNA and then amplifies the DNA for detection.

There is much written about the shortage of “kits”. These are now available

https://www.biovision.com/coronavirus-sars-cov-2-pcr-detection-kit.html

Unique to a kit is the specific primers to identify the viral gene and the positive control for the disease.

The test subject must first be swabbed and the hope is that if the subject is affected by the disease:

  • He or she will be shedding virus onto the membrane that is swabbed
  • That the swab will pick up the virus
  • That the virus will survive the transport to the lab

Then the RNA needs to be extracted from the swab using a protocol similar to

The cotton tips were stored in 350 µL phosphate buffered gelatin saline (PBGS). For the extraction, the cotton tip was lifted out of the PBGS and placed in a clean microcentrifuge tube. The extraction was conducted using the RNeasy Plus Mini Kit (QIAGEN) following the manufacturer’s instruction for tissue samples.

Habarugira, Gervais, et al. “Mosquito-Independent Transmission of West Nile virus in Farmed Saltwater Crocodiles (Crocodylus porosus).” Viruses 12.2 (2020): 198.

The extracted RNA needs to be processed in a qRT-PCR machine using the kit. Machines are available as 96 or 384 well devices – this is the number of simultaneous tests that can be done.

The test run takes 2-3 hours to do.

There has been some promising development of a new test for the virus known as RT-LAMP https://www.medrxiv.org/content/10.1101/2020.02.19.20025155v1

The new test uses a different enzyme for dna polymerization and does not require thermal cycling. Theoretically, the test could be read by naked eye in the field

Although this is yet to be validated on real virus or virus samples, it is a very positive development. The test could theoretically be done in the matter of hours at the doctor’s surgery