CDC: U.S. coronavirus spread expected, ‘disruption may be severe’

Short of declaring COVID-19 a deadly pandemic, U.S. public health authorities anticipate community spread of the novel coronavirus and warn "severe" disruptions likely in the event of an outbreak.

In a U.S. Centers for Disease Control and Prevention (CDC) telebriefing Feb. 25, Nancy Messonnier, M.D., National Center for Immunization and Respiratory Disease director, said a global COVID-19 outbreak is only one criteria short of "pandemic"-that being, worldwide viral spread. This, despite World Health Organization (WHO) numbers released that same day showing 80,239 confirmed cases globally in 33 countries (as of March 5, 85 countries now report confirmed cases).

In a further blow to global containment efforts, four countries reported COVID-19 cases in the 24-hour lead-up to the WHO report, as well as suspicion of under-reporting of severe cases in Iran and an outbreak in Italy where 3,089 cases prompted city-wide quarantine and sweeping closures. Still, WHO data shows most COVID-19 cases remain in the country of origin; China confirmed 80,565 cases and 3,015 deaths (as of March 5) as compared to the 14,768 confirmed cases and 267 deaths outside of China.

"Cases of COVID-19 are appearing without a known source of exposure," Dr. Messonnier said Feb. 25 of community viral spread globally. Those situations prompted U.S. authorities to implement an aggressive containment strategy in recent weeks, including mandatory quarantines of at-risk people. To date, there are very few COVID-19 cases in the U.S.—99 cases and 10 deaths as of March 5—and no extensive community spread, but the CDC doesn't anticipate that lasting for long.

"Ultimately, we expect we will see community spread in this country," Dr. Messonnier said. A week later, at least five states would declare states of emergency to coordinate their local COVID-19 responses. "It's not so much a question of if this will happen anymore, but rather more a question of exactly when this will happen and how many people in this country will have severe illness."

Currently, the CDC classifies COVID-19 as a 'high' public health threat as illnesses range from mild to severe, including illness resulting in death. A respiratory disease in the same family as the common cold, Middle East Respiratory Syndrome (MERS) and Severe Acute Respiratory Syndrome (SARS), COVID-19 (also known as SARS-CoV-2) could be equally as virulent as SARS and MERS but even more so than seasonal influenza or norovirus.

Such concerns are driving fears that a U.S. outbreak is possible, and with no vaccine or medications approved to treat COVID-19, the CDC posited a series of non-pharmaceutical interventions (NPIs) in response to local conditions. Those NPIs come in three forms:

• Personal NPIs — Personal protective measures, including voluntary home quarantine.
• Community NPIs — Measures to limit exposure among communities, including school closings or tele-working options.
• Environmental NPIs — Measures to limit exposure in the environment, including cleaning frequently contacted surfaces or objects.

"I understand this whole situation may seem overwhelming and that disruption to everyday life may be severe, but these are things that people need to start thinking about now," Dr. Messonnier implored.

AOA HPI engages public health community

The AOA Health Policy Institute (HPI) has closely monitored developments and actively participated in U.S. public health discussions to date regarding COVID-19 to ensure doctors of optometry not only understand the risks associated with this outbreak but also have the latest information available for continued patient care.

Earlier this month, AOA HPI representatives joined a public health forum with officials from the White House, CDC and National Institutes of Health where it was first learned that the CDC would begin pandemic planning. Among other strategies, those plans proposed:

• 'Social distancing' to decrease mass gatherings, such as school closings, postponing conferences or concerts, and encouraging remote workplaces.
• Personal Protection Equipment (e.g., face masks) should be reserved now for health care providers and sickened individuals.
• At-risk travelers entering the U.S. will be quarantined for a 14-day protective period to ensure they are disease-free.
• There are no U.S. drug shortages for medicines repurposed for COVID-19 treatments.
• CDC is upping outreach to health care systems nationwide about infection control protocols and to prepare for surges in people seeking care.

"The containment measures of quarantine simply slow the introduction of the virus into the U.S., and this buys us some time—perhaps weeks—to prepare for this tremendous public health threat," says Michael Duenas, O.D., AOA chief public health officer.

"As frontline health care personnel, doctors of optometry should be prepared to evaluate patients for COVID-19 and they should also know that they, themselves, will have a greater risk of infection."

COVID-19 information for optometry

In an updated statement released Feb. 24, the AOA HPI consolidated the most up-to-date information on COVID-19, general public health guidance and infection control protocols that all doctors of optometry should be conscious of and actively employ, bearing in mind the evolving nature of this outbreak.

Even the WHO and CDC acknowledge current understanding of the disease remains limited, but there are several points that doctors of optometry need to know in the event of an outbreak, including:

• Frequently reported signs and symptoms of COVID-19 include: fever (83-98%), cough (46-82%), myalgia or fatigue (11-44%), and shortness of breath (31%) at illness onset. Less commonly, patients report sputum production, headache, hemoptysis, diarrhea or nausea. The fever course of COVID-19 infection isn't fully understood; it may be prolonged and intermittent.
• As of Feb. 10, the secondary attack rate of transmission for COVID-19 was reported as high as R ₀ 4.08, indicating that on average every case of COVID-19 would create 3-4 new cases.
• Although viral conjunctival infection is usually caused by adenovirus, COVID-19 may cause ocular signs and symptoms, including photophobia, irritation, conjunctival injection and watery discharge. The latter may be a potential source of contamination while the eye can be a route of exposure. Personal protective equipment (PPE) is required for the patient and care team.
• Ensure strict adherence to infection control protocols, no matter the office size or setting. Vigilance and proper hygiene-thorough handwashing, PPE use, disinfecting equipment and other recommendations provided by the CDC-in the office when in contact with bodily fluids, such as tears, can help prevent infection. Practices should keep 60-95% alcohol-based hand sanitizer, no-touch disposal receptacles and facemasks in waiting areas and check-ins, Dr. Duenas adds, in addition to visual signage reminding patients of hand hygiene and cough etiquette.
• Be mindful of commonly understood characteristics of COVID-19, as well as patients' exposure risk, noting that many signs and symptoms of COVID-19 overlap with those associated with other viral respiratory tract infections. Therefore, CDC offers this checklist for transport or arrival of patients with possible COVID-19.

Given the evolving nature of this outbreak, doctors of optometry should routinely track the progression in the number of suspected and confirmed cases in their state. Dr. Duenas notes that the high secondary attack rate of COVID-19 shows that every case could create three to four new cases, making social distancing necessary in lieu of a vaccine. This could inevitably have an impact on manufacturing and supply chains.

"Doctors of optometry can prepare their offices by understanding which drugs and medical supplies might be disrupted as a result of manufacturing delays and quickly stock up on those essential to the practice," Dr. Duenas says. "Additionally, they may want to consider ways to distance patients in waiting rooms and establish fixed protocols for all doctors, patients and staff to reduce person-to-person transmission."

For any patients meeting criteria for COVID-19 evaluation, clinicians are encouraged to obtain a detailed travel history and to collaborate with state or local health departments. Find the CDC's guidance for health care professionals.

Stay informed with the AOA's COVID-19 guidance and resources

The AOA continues to closely monitor all developments in the U.S. public health response to COVID-19, as well as institute an all-out mobilization on behalf of the profession that includes not only 24/7 advocacy for optometry, but also launching an  unprecedented, multifaceted relief and recovery package.

Given the evolving nature of this pandemic, the AOA remains committed to providing the most up-to-date information, relevant care guidance and resources, and timely reports on federal actions through  AOA's COVID-19 Crisis Response page. This online resource includes:    

• New recommendations for the reactivation of optometry services in the form of  AOA's Optometry Practice Reactivation Preparedness Guide.
• The AOA Health Policy Institute's  "Doctors of Optometry and COVID-19" statement and  FAQ.
• #AskAOA COVID-19 webinar series.
• State-by-state COVID-19 resources and information.
• Latest information from  CDC and  White House Coronavirus Task Force.