Looking to the Future to Prepare for Covid-19’s Second Wave
A physician and researcher in China for the Covid-19 pandemic, Ewelina Biskup, MD, MPH, discusses that experience, and calls for a big data collection and analysis effort to address the many unanswered questions about the virus.By
- Ewelina Biskup, MD, MPH &
- Edward Prewitt, MPP
Vol. 1 No. 3 | May — June 2020NEJM Catalyst Innovations in Care Delivery 2020; 03DOI:https://doi.org/10.1056/CAT.20.0106
Summary
China’s strict and interrelated clinical and social protocols played a key role in its dealing with the first phase of the Covid-19 pandemic. While many now are looking to colleagues for lessons as the novel coronavirus spreads globally, unanswered questions remain regarding long-term side effects, prospects for organ or tissue damage, identification of prognostic biomarkers, and development of therapeutics. Ewelina Biskup, MD, MPH, calls for robust data recording and the creation of a big data set to support analysis to improve care for the next waves.
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Edward Prewitt, MPP, interviews Ewelina Biskup, MD, MPH, Associate Professor, Shanghai University of Medicine & Health Sciences, and Jiaotong University School of Medicine in Shanghai, China, and researcher, University Hospital in Basel, Switzerland.Ed Prewitt:
Hello, this is Ed Prewitt, Editorial Director of NEJM Catalyst. I’m speaking with Ewelina Biskup, MD, MPH, who is Associate Professor at Shanghai University of Medicine & Health Sciences and Jiaotong University School of Medicine, and is also in a research position at University Hospital in Basel, Switzerland. Ewelina is in Shanghai right now and has a lot of interesting observations about living in China amidst the Covid-19 outbreak, as well as advice for other countries.
Ewelina, thanks for joining us.Ewelina Biskup:
Thank you for inviting me. I’m happy to connect.Prewitt:
Would you please begin by describing your experiences with Covid-19 in Shanghai, as well as your observations about the outbreak within the quarantine zone of Hubei?Biskup:
As a medical doctor in China, I have to say that I have been fortunate to be here in Shanghai during the outbreak. First of all, the number of cases in Shanghai is comparably low. We only have about [500] cases overall and few fatalities, luckily, which is different in Hubei where the numbers have reached over 60,000 and many more deaths.*
The curve is now flattening, and I have observed a lot of measures that the Chinese government and Chinese health care system applied and implied, and they have turned out to be effective and efficient. Especially now, looking at what’s happening in Europe and the USA, many lessons can be learned from China and I hope that they can still be translated into reality in many countries.
The observations experienced in Shanghai were sobering. I arrived shortly before the peak of the cases, shortly before the so-called clinical diagnostic criteria had been released and the peak of the numbers had been announced by government.
It gave us doctors a lot of comfort to know that there is not that much anxiety to get infected from the patient. Even if they were suspected, they were immediately transferred to Covid-designated clinics.
I had seen, upon landing here, everybody under quarantine and a strict social distancing applied. The observation in daily life has been interesting. There has been a triage, not only of patients, but also of normal people, like society. For example, every compound, every building had guards at the entrance who were measuring temperature when entering and exiting the building. No nonresident was allowed to enter the building.
And [in] similar strategies, strict triaging was applied for the hospital. What is important to know is that physicians who were not at the front line, physicians who were not designated to treat Covid patients barely had any contact with patients that were suspected even with the infection. There were designated clinics in the town, and they were well announced; every potential patient, every citizen, knew which clinics were those designated ones. All the other clinics were working pretty much in the routine way. However, even if a patient arrived at the clinic there were several gatekeepers — literally — so even at the gate there was, again, a check of temperature and some basic symptoms.
Further, the patient went for the triage with a nurse who was doing a more intensive epidemiological and symptomatical analysis, and only when everything was negative did the patient arrive to see the doctor. It gave us doctors a lot of comfort to know that there is not that much anxiety to get infected from the patient. Even if they were suspected, they were immediately transferred to Covid-designated clinics.
Similar things were done in Hubei where super-hospitals were built in 10 days, which was phenomenal. The infrastructure was there and all the doctors were protected with [personal protective equipment] PPE and masks and special guards and garments.Prewitt:
What was the clinical response and the social response, and the interplay of these factors?Biskup:
This is an important question. The clinical response and the social response were very much interrelated and there was a balance between those, and even a slight disturbance would probably lead to subtle outcomes. On the one hand, clinically, there was a massive response from the physicians. There were teams mobilized to Hubei Province from all the provinces of China, and not only physicians were going to Hubei to help out, but they also went together with their equipment.
The radiologists were working day and night because radiological findings, the CT scan, was and is one of those criteria that can define a patient even before a serological test is being done. This was helpful at the beginning, but we have to remember that all the things that we know now we didn’t know then, back in January and February.
Clinically, doctors were well informed, and the communication from the government down to the physicians and to potential patients and to society was effective. There were clinical guidelines that were developed and updated constantly. I recall that we have received through social media and through our channels — specific medical channels on WeChat —updates almost every day.
She immediately took [a mask] out of her pocket — although it was such a valuable piece of important prevention — and she gave it to me. Socially, people were supporting each other very much.
We were advised that in case we have any symptoms, fever, whatsoever, we are supposed to stay home; we are not allowed to go to the hospital. This was definitely one of the important clinical responses. Nobody was forced to go to Wuhan to help out, or to help out in the designated clinics [for] Covid patients — the patients with Covid were never [mixed] with normal patients, comorbid patients, and so on.
On the social side, what I have observed, which was extremely interesting, was that the society responded very well. Communication was at the level of health literacy, which cannot be assumed is at a very high level. A big part of society is older people, and even they were stringent with the social distancing, were wearing masks. We were not allowed to leave our homes without a mask, not even to mention going to a show or any public space without a mask. Every entrance to every public space and even the residential houses always had protection with temperature checking, with registration, and so on.
Even until now, everybody has an electronic QR code1 that we have to update every week, and this QR code is allowing us to go to specific places, and there’s a whole algorithm behind it.
Although there was a shortage of masks, to give an example of social response, I forgot my mask once in the elevator and I was there with an older Chinese lady. She said to me, “You have to wear a mask for your own protection.” And I said, “I just forgot. I don’t have it.” She probably understood that I do not possess one. She immediately took one out of her pocket — although it was such a valuable piece of important prevention — and she gave it to me. Socially, people were supporting each other very much.Prewitt:
That’s fascinating and very stringent. When we were speaking before, you mentioned that you had conducted a survey of Chinese physicians. Could you please tell us about that, what were the goals of the survey and the respondents and your findings?Biskup:
We were curious about those physicians who are not at the front line, but those who are supporting the entire rest of the population medically, helping with the situation, with the quarantine, with treating patients under the constant fear of potentially being infected, and we had about 450 responses. I will highlight the most interesting findings, which I found impressive.
About 20% of the responders stated that they needed psychological support during that time, and I was happy to see that 18% answered that they actually used them.
While the outpatient number was reduced by about 50%, the inpatient number was pretty stable. And while about 50% of all the responders stated that they were afraid that they could be infected by their patients, they still continued working, and — this might be an interesting point applicable for Europe and the U.S. — there were available psychological support sites specifically for medical workers, among those physicians. About 20% of the responders stated that they needed psychological support during that time, and I was happy to see that 18% answered that they actually used them. Those were really in demand. They used the resources and the resources were in place, something we learned from the SARS and MERS epidemics and that was translated into reality very quickly — there were many options to get support.
What we were also interested in was to see if those physicians here in China considered leaving the medical profession or if they considered switching into being a medical professional but not in clinical settings, switching for example to industry. Consistently about 11% to 15% of physicians stated that they had those thoughts; they were hesitant. But at the end of the day, they did not make any steps toward it.
Last but not least, we asked the physicians how much did they use digital medicine and telemedicine during that time. Many of the follow-ups and consultations were immediately transferred into digital tele-bases, which were available and are used usually [at normal times] but were much more exploited during the crisis. Many of the doctors, 45%, said that they see telemedicine as a good alternative in the future, so this is a positive development.Prewitt:
One takeaway from this survey is that the care of physicians and medical professionals during this outbreak has been high, has been strong. There have been measures implemented to assure their health and protection. Do you think it’s been sufficient?Biskup:
I think it has been sufficient. All the physicians were well prepared. They have been briefed about the disease. They have been constantly updated with novel [coronavirus] updates, whatever there was in terms of research, in terms of guidelines, in terms of measures from the government. And they have been prepared and even [given] the free choice if they would like to help at the front line or not. Many of them did, so we saw huge solidarity and unification during that time.
The panic and the mass hysteria that is being observed all around the world was not very present here in China and this has helped health care professionals to proceed systematically and consistently, to really succeed in terms of focusing on patient care.Prewitt:
What is your advice for hospitals and health care professionals in other countries?Biskup:
I am looking at Europe and the U.S., and I’m receiving a lot of questions from my peers, from colleagues, and even from doctors I do not know asking about clinical advice. My advice would be a maximum of protection, but I know this is difficult. Another [piece of] advice would be to look more into radiological testing, while in several countries there is not a sufficient amount of tests that can be performed in the clinic.
But overall my main message — because all the other messages are out there and I know that it is difficult for many reasons to achieve what China has done — what we should do is to look into the future, because at this moment we do not know what will be the long-term side effects of this virus. We do not know what type of further organ tissue damage this virus might cause. We assume that there will be permanent lung damage and it’s possible, but we cannot predict yet what might be next.
This is why I would definitely appeal that we should record as much data as possible, even if it’s just clinical cases, because if we can create a big data set, then we can translate those data into health trajectory and can react faster in the future.
Some of the questions are very important right now. For example, I have been asked if there is any good biomarker for prognosis and prevention and for checking the disease. At this moment we do not have it. We are using the basic markers that we have, markers of inflammation, which are not really very useful. We do not have a biomarker of severity, so we do not even have a strategy for personalized treatment. I would say this would be the highest priority, collecting as much data as possible.
From the personal point of view, I know it’s difficult, but I suggest to stay as calm as possible. The panic and the mass hysteria that is being observed all around the world was not very present here in China and this has helped health care professionals to proceed systematically and consistently, to really succeed in terms of focusing on patient care. We were also not as much overwhelmed with a lot of information that is the case right now. On the one hand, it is very good that there are so many clinical trials and so much information coming from different sources. On the other hand, it’s very difficult to filter them.
We should record as much data as possible, even if it’s just clinical cases, because if we can create a big data set, then we can translate those data into health trajectory and can react faster in the future.
So, keeping focused on the medical care and thinking about the future would be my core advice.Prewitt:
Based on what you are seeing and hearing around the world, are you optimistic or pessimistic about the course of Covid-19 over the next few months?Biskup:
I am reluctantly pessimistic about how the cases of fatalities will develop. Any loss of life is tragic, so I would be hesitant in saying that everything will be fine. But there will be an end to it. From the Chinese perspective I can say in Shanghai, life is getting back to normal — although there are still stringent policies in place in order to protect us all here, and in terms of the global perspective, from the second wave.
There are still strict rules, for example, about the quarantine of people who are returning to China. They’re extremely strict, beginning quarantine at the airport. Over 3 months this has been a constant learning process. We have been learning about the test, we have been applying the test first in the centralized lab and moving them into the clinics. The same of them for the triage. Now, the returnees are not being quarantined in their homes, which had been done for the last 3 weeks, but only in designated places in the hospitals. That’s important.
It is also important to look at the positive in order to be a little optimistic. This epidemic has taught us a lot and put more emphasis on health care in general, and at the end of the day we realize how important the medical profession is. I hope that doctors will regain their confidence in the choice of their profession. We see a lot of collaboration and coming together of biomedical research, and this is important as a resource for the future. We have seen that many research funds have been released quickly and there has been a lot of facilitating of processes in terms of trials, initiations, and so on.
We have seen that China has leveled to the West, or in terms of preparedness perhaps even overrun the West in some terms. What has received a big push through this crisis is personalized medicine and the use of big data and artificial medicine in order to target hypotheses and rapidly discover drugs or even create molecules toward new treatments. This will allow us in the future to quickly repurpose the possibilities, and in this sense, China is at the forefront.Prewitt:
Ewelina, thank you so much. This has been fascinating, really informative. The readers and listeners of NEJM Catalyst around the world will benefit.Biskup:
