Abraar Karan: To control the covid-19 outbreak, young, healthy patients should avoid the emergency room

Young, healthy people with symptoms of covid-19 can help to prevent outbreaks in emergency rooms where our society’s sickest will be seeking care, says Abraar Karan

abraarThe situation with covid-19 is rapidly evolving, and is coming to a critical point, with 72 countries now affected outside of China and more being added to that list every day. Outbreaks in Italy, Iran, and South Korea are growing at pace, and it is only a matter of when for many other countries. As public health experts and doctors, it’s been worrying to witness the rapid spread of covid-19, and the relatively high hospitalisation rates of patients—especially those needing care in intensive care units. In these early phases of the epidemic, the case fatality rate is turning out to be much higher than the seasonal flu. As we begin to see bigger outbreaks in more major cities globally, we are going to need a smart, systems level response, particularly while we do not have a vaccine, cure, or rapid diagnostic tests available. 

One critical action will be for young, healthy patients with mild symptoms of fever, cough, and shortness of breath who may have covid-19 to avoid going to the emergency room. 

From early studies out of China, we know that around 80% of cases are mild, and the majority of healthy young adults, children, and infants have only got mild symptoms. This group of patients will most often not require any hospital level care and will get better on their own at home. However, if they come to the emergency room, they will end up spreading the virus to those who are at serious risk, notably older people and those with other medical conditions, such as diabetes or heart disease. These vulnerable groups have significantly higher rates of hospitalisation and death from covid-19. This is not to say that a young person would never get severe disease—they certainly can, and in that case they would need to be seen in a hospital—but the vast majority will not.

Young, healthy patients should instead call their primary care doctor or nurse to discuss symptoms, and will likely be recommended to self-isolate. In some parts of the world, including the UK, people with suspected covid-19 are being tested in their homes as part of efforts to stop unnecessary ambulance use and hospital visits. Current estimates suggest that this period of self-isolation should be for around 14 days from the onset of symptoms. This simple action by the young and healthy could help prevent community spread but, most importantly, prevent outbreaks in emergency rooms where our society’s sickest will be seeking care for both covid-19 and other medical conditions. 

Aside from preventing transmission, this important action will help to ensure that our doctors, nurses, and other healthcare professionals are able to focus limited resources on those who will need them most. From our Chinese data, we are seeing quite a significant proportion of those who are sick requiring hospitalisation (somewhere between 15-20% per early estimates), and many of those requiring intensive care in critical care units (5-26% based on recent studies from JAMA and NEJM). Our healthcare systems, even in wealthy countries, do not have the capacity to handle this level of hospitalisations if covid-19 spreads to even a small percentage of our societies. The hope is that these hospitalisation rates will turn out to be much lower, especially because early on in an epidemic, reporting mechanisms tend to catch many more severe cases and undercount the mild or asymptomatic cases. However, we need to prepare for the worst.

To operationalise this, health systems will need to employ large scale channels of communication, likely mobile based, by which they can easily contact all people to reinforce these critical messages, and by which to do remote screening. Over the phone, doctors can screen people who think that they are at risk by asking basic checklist items, such as vital signs, symptoms, age, and comorbidities while people are in the safety of their homes. This will allow healthcare professionals to quickly decide who actually needs to be evaluated in the emergency room, and who should remain at home where they can safely recover and limit the risk of infecting other people. 

One obstacle is that many people do not have access to primary care doctors, especially in the US. To overcome this barrier, health systems need to have call lines by which all people can reach a physician, nurse, or other healthcare professional to begin screening. Community home testing will be an important step if initial screenings are suspicious for covid-19. 

Another considerable concern is that self-isolation for 14 days puts people out of work—an impossible prospect for the many people who can’t afford this luxury. The economic consequences will be severe if a large proportion of any society cannot work, and this is something that political and economic thought leaders need to address. 

We need many things right now—rapid diagnostics, vaccines, antivirals with proven benefit—but these could take several months to materialise. We have to instead rely on what we do have at this moment, which is our ability to communicate effectively at scale, minimise spread of disease by self-isolating appropriately, and freeing up valuable medical resources to be focused on those who will need them most. Let’s make sure we do this right. 

Abraar Karan is an internal medicine doctor at Brigham and Women’s Hospital and Harvard Medical School. The views expressed here are his own and do not represent those of his employers. Twitter @AbraarKaran

Competing interests: None declared.