The Path Forward Light at the End of the Pandemic Tunnel

There are signs of light at the end of this tunnel. There is a path forward beyond these dark days of quarantine. Even as the invisible threat of a viral pandemic continues to spread across the globe, we must prepare for tomorrow. As we navigate through the most difficult days battling the novel coronavirus, the race is on to find the tools to win the war on COVID-19. The health care workers on the front line of the battle are caring for those most critically ill. Scientists are working to develop accessible point-of-care tests, treatments, and ultimately a vaccine. And we the world are at home waiting. Quarantined to flatten the curve. Waiting for the other side. For a time when we can reemerge into what surely will be a new world. As we pinnacle at the peak of the viral pandemic, it is critical that we maintain these extreme stay at home measures and quarantine to hold the line. However, we must simultaneously start planning for the other side. Resilience, innovation and strategic planning are key to pivoting to the new reality we will surely find.

Understanding the Impact of Illness

Our tomorrow will not resemble our pre-pandemic yesterday. Our near future will require new strategies to ensure the health and security of those emerging from quarantine and to simultaneously protect those at high risk and most vulnerable to COVID-19. We have no prior experience with this viral threat, SARS-Cov2, the novel coronavirus that causes COVID-19. This means that we had no prior immunity to protect us. But as some of us (likely fewer than 10% so far) have been infected and recovered, there may be some short term immunity from recent past infection (although the WHO suggests we should not rely on this natural immunity as its robustness and durability are presently unknown). Ultimately it is unlikely that this coronavirus which has already spread around the world will suddenly disappear. Instead, it can be expected to become the 5^th coronavirus that persists globally adding to the other 4 coronaviruses that account for our seasonal common cold. These seasonal varieties are far more indolent than the other two more virulent coronaviruses: SARS of 2003 and MERS of 2012. As SARS-Cov2 works its way through the community most can expect to experience mild disease; a cough, sneeze, sore throat, fatigue, and possibly loss of taste and smell (the latter of which are the most specific symptoms). Children, for instance, are largely asymptomatic or affected so mildly that they are considered carriers. For this reason, COVID-19 can be considered a wake-up call. With a virulence factor less than other recently encountered viral pathogens like SARS, MERS, Ebola and the avian flu (H5N1) at 60%, our present pandemic may be considered a fire drill to the eventual big one. It is key to win this battle emerging smarter, safer and more prepared for the future.

The Promise of Technology

Innovation holds the promise of helping us reach the other side while minimizing loss of life. There are three key areas where innovation is needed: testing, treatment and ultimately a vaccine. Testing is key to understanding the prevalence of infection, the virulence and fatality rate and ultimately to implement any management strategy. Point-of-care testing of immune status provides real time information on an individual’s risk status. For instance, the presence of antibodies indicating recovery from a past infection with COVID-19 can be used to deem someone safe to return to work. Improved access to point-of-care tests will hasten our economic recovery. With treatment available to limit disease, lower risk individuals may reemerge sooner with the confidence that potential infection can be successfully medically managed, preventing progression to critical illness and death. At present, there are no treatments available for mild disease. Convalescence at home is the only option. For those who develop serious symptoms of respiratory distress, intensive care and ventilation are usually required. Numerous pre-existing therapies have been identified to be repurposed for the care of those who become ill with COVID-19. Ideally these treatments will be used in those with intermediate illness to prevent progression of the illness and limit fatality. Drugs to treat malaria, rheumatologic illness and other infectious diseases are being evaluated. Many of these have serious side effects and to date most have not shown clear benefit. Natural compounds like vitamin D3, vitamin C and zinc have established benefit in reducing illness from other coronaviruses. With a favourable safety profile these are options for prevention and ameliorating mild illness. Serum from recovered patients containing antibodies that confer immunity, referred to as convalescent serum, is being used experimentally. Ultimately a vaccine will be required. Though the long timeline to its widespread availability means vaccination is not a near term solution. A vaccine offers future promise of immunity without the threat of infection but its widespread commercial availability as a safe and effective tool is likely at least 18 months to 2 years away.

The Path Forward

Innovation and technology will be key to success on the path forward. As the world’s scientists race toward these advances, our resilience is key. We must actively plan to pivot out of quarantine navigating a new normal. Progressive steps back to normalcy. The path forward will likely have three phases.

Phase One: Hold the Line

Holding the line will keep our curve flat. In order for us to keep minimized the daily COVID-19 fatality rates and new case rates, we will need to extend further the extreme measures of quarantine, stay at home directives, physical distancing and closure of schools and all non-essential services and businesses. We are already seeing the benefits of these measures in ensuring that our health care system can respond to the needs of the critically ill. Holding the line with continued extreme containment efforts should ensure that sufficient ICU beds, ventilators and healthcare workers are available to meet the needs of those who fall seriously ill. With a well planned lessening of these measures for low risk individuals, our health care system will have a better chance to manage the expected uptick in demand for care.

Phase Two: Cautious Re-emergence

In the coming weeks, we can anticipate a relaxation of stay at home directives for lower risk individuals. With hope, our children can return to school by June. Parks will again be accessible. Limited businesses will re-open, restaurants, shops, and other public serving institutions that have been shuttered for weeks will be able to serve their customers but with strict guidelines in effect. Physical distancing to be maintained in public indoor spaces. Public gatherings will be limited in size. Enhanced cleaning and disinfection will be mandated for high touch surfaces like playgrounds and public transportation. Informed by the experience of working at the front line during SARS and H1N1, infection control procedures are familiar. As a doctor-owned clinic, we are prepared with necessary protocols and procedures: virtual options for consultations and care, pre-visit screening, enhanced cleaning and disinfection, improved ventilation, and increased access to PPE to protect our team and patients. We are ready. But we will all need to continue to protect and support our most vulnerable during this transition. High risk individuals whom are able to, should remain in protective self-isolation, while those who live or work in high risk environments should be protected with enhanced testing and PPE.

Phase Three: Our new Normal

By late fall, we likely will have reached a new normal. Productivity will rebound slowly with protective measures and infection control still in effect. A second wave of COVID-19 is likely. The resurgence of infection at this time may arise from the combined effect of seasonal changes compounded by exponential spread of infection as society moves away from physical distancing measures. Success through phase three will depend on innovation and eventually a vaccine. Until such time, increased virtual connectivity and commerce will be the new normal. Resilience and reinvention will allow our community to remain strong -tied together in new ways. There is light at the end of this pandemic tunnel. The first glimmer is on the horizon. To reach it we must adapt to a new reality. The reality of a new normal that awaits us on the other side. Prepare for three phases on the journey to our tomorrow. Resilience, innovation and strategic planning will be the keys to our success. We will conquer this challenge and be stronger together. Sincerely, Dr. Jennifer Pearlman Dr. Pearlman is a medical doctor in Toronto, Canada. She is owner and Medical Director of PearlMD Rejuvenation a Precision Integative Medical Clinic offering expert medical care, leading technology and treatments to help patients achieve Ageless Vitality. Dr. Pearlman is an internationally recognized expert in Women’s health, hormones, aging and cosmetic medicine.