A nurse in a hazmat suit packages a completed test for the coronavirus to be sent to a lab in Somerville, Massachusetts, on March 18. JOSEPH PREZIOSO/AFP VIA GETTY IMAGES
Article initially published in Foreign Policy on March 24, 2020 and written by Annie Sparrow.
Health workers are our most valuable resource for combating the coronavirus pandemic. They are also among the most vulnerable. During the SARS coronavirus epidemic in 2003, 20 percent of those infected globally (1,701) were health care workers. We tend to focus on age as a risk factor for COVID-19, but the biggest risk may be being a health worker, of any age.
The consequence extends well beyond the individuals infected. Every health worker who sickens or dies from COVID-19 reduces the capacity of the health system that cares for us all. Yet, there are important steps that public health authorities could be taking right now to better protect health workers, and only a lack of imagination is stopping them being used.
As an intensive-care pediatrician and public health specialist, I have worked in many of the world’s worst outbreaks, several of them in war zones. As with many of my colleagues around the world, this is not my first pandemic. Yet, for the first time, I am filled with dread, even despair. Why?
Even in the best of circumstances, medical staff are at risk. In any emergency room, it is a given that we often have to get close to our patients to save them—to do CPR, intubate, ventilate, and resuscitate. When time is of the essence, few of us will let our patient die for the want of an N95 mask. We risk it.
These are not the best of circumstances.
Today, health workers are at great risk for several reasons. Medical personnel are exposed to more viral particles than the general public. That means they’re both more likely to get infected and likelier to have worse cases when they do—which may be why so many younger Chinese doctors died. Protective equipment is in short supply as the tide of patients rises. And a combination of stress and long hours probably makes the immune systems of health workers more vulnerable than normal. This combination turns hospitals into hot spots of transmission—coronavirus “pumps.”
Since the beginning of this pandemic, many front-line health workers have paid the ultimate price. The doctors in Wuhan who first raised the alarm not only were silenced by Chinese authorities, but several died of the virus. The pathogen does not discriminate among specialties. The first fatality among them was Li Wenliang, a young ophthalmologist—not a profession normally considered high-risk. His colleague Mei Zhongming, who died the following month, was also an ophthalmologist. A third was a thyroid and breast surgeon. A fourth, a neurosurgeon and hospital director. In Britain today, two ear, nose, and throat specialists are in critical condition.
We don’t even have accurate numbers about the number of health workers infected or killed. China has never released accurate figures—just as it has never released an accurate count of the total number of people who died from COVID-19. (If you died without being tested for COVID, Beijing says, you didn’t die of COVID.)
For six weeks, China insisted that only 13 doctors had been infected, lulling us into thinking that spread within hospitals was not a concern and could easily be prevented by standard masks and gloves. Suddenly, on Feb. 14, the announced number skyrocketed to 1,716, more than the medics infected throughout the entire SARS epidemic. By Feb. 20, the World Health Organization mission in China reported 2,055 lab-confirmed COVID-19 cases among health workers. By March 3, China estimated up to 3,200 had been infected.
By contrast, Italy consistently reported high rates of infected medics—about 8.5 percent of total infections, or 20 percent of their health care workforce. In Spain, over 4,000 healthcare workers have been infected.
And these are well-prepared countries. In less-developed parts of the world such as much of sub-Saharan Africa, weak health care systems and inadequate infection control measures—a lack of running water, let alone disinfectant or isolation rooms—means overburdened staff are at exceptionally high risk. The same is true in areas of conflict such as Yemen and Syria, as well as crowded refugee camps and sprawling urban slums. All of these areas are prime targets for the coronavirus.
When there are no doctors to intubate, no nurses to provide care, the death rate will skyrocket. And not just from COVID-19. None of the usual killers—such as heart disease, cancer, and car accidents—are conveniently suspended during a pandemic.
We all know that using personal protective equipment and related protocols are essential. Yet, even when health workers are in a full moon suit, virus particles can often find a way to infect them. Institutions can equally fail in their duty to protect health care workers. When two nurses in Dallas were infected with Ebola in 2014, the Centers for Disease Control and Prevention contended that it was due to a breach in protocol—but the nurses said no protocols had been established in the first place. When a Californian nurse caring for a COVID-19 patient developed symptoms and requested a test, the CDC refused, saying if she had followed protocol, she wouldn’t have been infected. (The CDC subsequently changed its protocols for both cases but has never apologized to the nurses.)
In any event, today there are not enough N95 masks, gowns, suits, and goggles to go around. Given the uncertainty, risk, and fear surrounding this disease, it is hard to have the confidence needed to care for patients well. For those with families and children they spend time with after their shifts, it is even harder.
For both pragmatic and humanitarian reasons, protecting health care workers should be our highest priority in fighting the coronavirus.
More beds, more hospitals, and perfect supply chains will all be redundant if there are no health care workers left or willing to take the considerable risks to fight the disease.
Yet there are things that could be done to better protect health workers. A vaccine for COVID-19 is a long way off, but certain other drugs may offer some protection. That does not mean adopting the various forms of quackery, snake oil, and supposed miracle cures that the panic of a pandemic tends to promote. Research protocols are not the same as rumors, anecdotes, and presidential tweets.
Yet one area worth exploring is the use of live vaccines to increase the recipient’s immune response. One such inoculation is called the Bacillus Calmette-Guérin vaccine, or BCG, which has long been used against tuberculosis.
Several studies in other contexts show that BCG primes the immune system to respond better to infections of various sorts, not just TB. Two studies in adults (one in patients aged 60 to 75) showed that BCG reduces respiratory infections by 70 to 80 percent. Two more reported a 15 to 40 percent lower risk of respiratory infections in vaccinated children. Another showed that, when given to infants in countries with severe health challenges and combined with a revived immunization scheme, BCG cut deaths from all causes by just under a third. However, some studies suggest that this protective effect lasts only until an inactivated vaccine (such as an influenza vaccine) is later given.
Given this promising research, a systematic review commissioned by the WHO and published in 2016 concluded that the BCG vaccine had beneficial off-target effects and recommended further research. One such trial has just begun in the Netherlands. A larger trial of 4,000 health workers is due to start next week in Australia. Others are being considered in Greece, Britain, Germany, Denmark, and the United States.
That protection would not be perfect—a BCG vaccination is not the same as a targeted vaccination for COVID-19—but it is likely to significantly reduce illness and death among those who receive it. Even if BCG vaccines were given only to health workers, we might substantially reduce the risks they face and lessen the risk of our hospitals and health systems collapsing. If effective, it could also be rapidly given to other particularly vulnerable people such as the elderly. It could be especially useful in countries that have weak health care systems and would quickly be overwhelmed by a large outbreak. And the vaccine is cheap, safe, and, most important, immediately available for testing. Health care workers must be the priority, but once manufacture of the vaccine is ramped up, it could be much more widely available.
Yet the big global institutions are dawdling. Despite the WHO’s recommendation, big public health institutions are not actively investigating BCG. Nor are global health foundations such as Gates funding this crucial research. While research and development into new drugs may be sexier, it is hard to understand the reluctance to explore nontraditional uses of existing drugs. The big pharmaceutical companies are also sitting on their hands, apparently because there is little profit in an established vaccine such as BCG.
Our global defenses are only as good as our front-line health workers. With so much evidence pointing to the potential for BCG to provide at least partial protection, it is indefensible, even unethical, to overlook it simply because this strategy is unorthodox and unprofitable. Trials to test its beneficial effects for COVID-19 are urgently needed.
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