Q&A: How has COVID-19 care transformed over the past year?
Last week marked the 1-year anniversary of the first confirmed case of COVID-19 in the United States.
Since then, there have been more than 25.4 million cases and 427,600 deaths in the country as of Jan. 28, according to the CDC.
There has also been progress: two vaccines are now authorized for use against COVID-19 in the United States, and Anthony S. Fauci, MD, director of the National Institute of Allergy and Infectious Diseases, said that Johnson & Johnson’s investigational COVID-19 vaccine could be authorized by mid-February. The company recently released data from its phase 3 trial that showed the single-dose vaccine was 66% effective overall in preventing moderate to severe disease and 85% effective in preventing severe disease 28 days postvaccination.
Treatment strategies have also progressed since the early days of the pandemic, according to Healio Primary Care Peer Perspective Board Member Lewis S. Nelson, MD, professor and chair in the department of emergency medicine and director of the division of medical toxicology at Rutgers New Jersey Medical School.
To learn more, we asked Nelson, who is also chief of service in the ED at the University Hospital of Newark and senior consultant for the New Jersey Poison Information and Education System, about how COVID-19 treatment has evolved over the past year, what advances he hopes to see this year, and more.
How has COVID-19 care transformed since the early days of the pandemic? What do you now that differs from what you did then?
At the beginning of the pandemic, we didn’t really understand what was happening to our patients. Over time, we learned why they were getting so sick so quickly, how to treat them and how to protect ourselves and others. We have gone from a position of fear to a position of understanding and, to some extent, a position of strength. We have a lot more to offer patients than we did back then. We feel much more comfortable with our personal safety, which is very important because it is hard to work when you feel like you’re at risk yourself.
In the beginning, the only treatment was supportive care. If you didn’t have enough oxygen in your blood, then we gave you oxygen. If your BP was low, we gave you fluids. Now there are both medications specifically directed to treat the virus, like remdesivir, as well as medications like corticosteroids that we give you to mitigate the immune response, which is, paradoxically, a big part of the problem with COVID-19. There are also treatments to actually enhance the innate immune response such as the monoclonal antibodies, and the preventive version of that, vaccines. We’ve learned a lot about virus and how it affects the body and causes the disease COVID-19. We, the medical system, have been able to come up with treatments that are, to a large extent, effective. People are obviously still dying, and there are people who have underlying conditions that prevent them from responding to treatment. But, overall, we have been successful in reducing the likelihood of mortality from the disease.
What are the biggest unanswered questions right now?
There remain a lot of unanswered questions. The biggest unanswered question is, what is going to happen tomorrow? You need a crystal ball for that. There are a number of models and we try to predict what will happen based on our understanding of the past and other contagious diseases. However, we cannot easily predict what will happen with people’s approach to the pandemic. There is a lot of COVID-19 fatigue, and people are struggling to stay home and quarantine, socially distance, wear masks and wash hands. This is to be expected after almost a year of doing this. That said, the way people behave is a tricky variable to predict in the models, especially in a stressful environment like this. We also don’t know what is going to happen with the virus itself, which is changing. There are alterations in the genetic makeup of the virus as mutations occur. A particular concern involved potential changes in the spike protein area, which may alter our ability to use existing technology to detect it on our tests, treat it with the medications that we have, and prevent it with the vaccines. As best we can tell right now, those are all still viable approaches.
Looking back, there are a lot of unanswered questions about this disease and why it is associated with some of the unexpected findings. We know there is an increased risk for developing thromboembolism — why? I don’t think we really understand that. We don’t understand why there is a population that suffers from prolonged effects post-COVID-19, which some call “long-haulers syndrome.” We don’t know why it exists, how common it is, and whether there is something we can do to prevent or treat it. These are all future questions we need to understand, but right now, we are still struggling to make sure that we can take care of people while they are infected and prevent infection.
How has this past year changed you personally as a physician? What are your biggest takeaways?
I have been so impressed with the way the health care system — and, really, the country and the world — have responded to the pandemic, despite the peaks and valleys. There have definitely been some curve balls thrown at us, but overall, researchers and clinicians have stepped up to the challenge.
Most of the time, when you go to work, you don’t expect to get sick. If you do, it’s usually a cold or something inconsequential. This is a disease where you are literally taking your life, and potentially that of your loved ones, in your hands. This is true for physicians and nurses, but it’s also true for nearly everyone else in the health care setting, including people who are involved with environmental services, transport patients, answer phones and register patients. It’s also true for non-health care workers on the front lines like bus drivers, police officers and delivery services. My impression of humanity has gotten much better. Of course, there those who refuse to participate in public health and public safety and those who feed misinformation to seed doubt and fear. That’s always to be expected. But I do think that, overall, we as a population have done the right thing to protect and support one another, particularly given the rapidly and frequently changing landscape of the pandemic.
For many clinicians, I think the pandemic has been really enlightening and inspiring. There is nothing better as a physician, particularly in my line of work, than to care for sick people. We would rather take care of one sick person than a dozen who are marginally ill. There has been no sicker population in my career than patients with COVID-19. So, in a sort of selfish perspective, this experience has been challenging and “enjoyable” because it is so satisfying to save someone’s life. That’s what we did for so many of these patients.
Where I am in New Jersey, we are not being hit very hard right now. However, back in April and May, you would literally turn around and there would be another patient dying right in front of you. It seemed that nearly every single patient who came to the hospital was that sick. We still have a number of patients with COVID-19 here in New Jersey, but we are able to manage with the workload. We have beds, we have staff, we have supplies. I hope it will get better than it is now, but we could live this way, if we had to, going forward.
What advances in COVID-19 care do you hope to see this year?
My greatest hope is that everyone will get vaccinated and that the vaccines continue to be effective. Prevention is the most important thing to me, it’s worth a pound of cure. Developing a highly effective therapeutic would be wonderful, but it would be better to eliminate the disease. We have been able to rid society of viral diseases in the past. We eliminated smallpox, we largely eliminated polio and we have kept measles and other diseases at bay. Of course, there are still a lot of people who are afraid or hesitant about vaccines, so I’m not necessarily going to get this wish without more education and data.
The therapeutics we currently have are better than nothing, but not great. We need something that works the way that penicillin did when it was first invented, particularly something that patients can take by mouth, at home, early on in the illness. None are silver bullets by any means. We need, again, a penicillin equivalent for the virus.
Still, I believe that the vaccination should be the most important focus right now. This will reduce health care needs, prevent death, limit virus mutation and help reopen society. It amazes me that there is so much rhetoric when it’s just so clear that if people get vaccinated, we would be in a much better place. There are a lot of politics and philosophy to address, and culture change going to be very hard to overcome.
References:
CDC. CDC COVID data tracker. https://covid.cdc.gov/covid-data-tracker/#cases_casesper100klast7days. Accessed Jan. 28, 2021.
Johnson & Johnson. Johnson & Johnson announces single-shot Janssen COVID-19 vaccine candidate met primary endpoints in interim analysis of its phase 3 ENSEMBLE trial. https://www.jnj.com/johnson-johnson-announces-single-shot-janssen-covid-19-vaccine-candidate-met-primary-endpoints-in-interim-analysis-of-its-phase-3-ensemble-trial. Accessed Jan. 29, 2021.