COVID-19 IN AMERICAS: ON-THE-GROUND PERSPECTIVES

UNITED STATES & NEW YORK

Dr Daniel Slaim, Regional Medical Director

9 April 2020

Current lockdown status: the United States is in a somewhat unique position, as stay-at-home orders vary from state to state, without a consistent national approach. On 19 March, the Governor of California became the first in the US to set mandatory stay-at-home restrictions to help combat the virus. All non-essential services have been shut down, while essential services, such as grocery stores, pharmacies, gas stations, delivery restaurants have remained open.

Residents who need to leave their homes to perform essential activities are advised to practice social distancing.

Most of the USA cases are in New York. The numbers of confirmed cases are increasing by hour, and public health experts are warning that the peak is far from being reached.

Impact on the community: Hospitals and medical staff in many locations are approaching capacity. All elective procedures have been cancelled, including non-urgent imaging diagnostics. Across the nation, there is a severe shortage not only of PPE, but also ventilators. In certain ‘hot-spot’ locations, the mounting pressure on hospitals has impacted the way emergency medical services (EMS) responds to cardiac arrest calls. For example, in NYC, there are reports that if the EMS cannot revive the patient on the scene, then, the patient will no longer be transported to the hospital.

While some states were adjusting to the new lockdown norm, ‘spring breakers’ were flocking to the sunny and warm beaches of Florida, drawing heavy criticism. Since that time, the governor of Florida had just issued a ‘safer at home’ order that went into effect 3 April and that will be in effect until 30 April. The order limits movement outside homes to provide or carry out essential activities. Other states have implemented similar orders, while some have no such orders in place.

With the closure of non-essential businesses, unemployment is sadly on an upward trend.

Just like everywhere else in the world, these are unprecedented times that have completely turned lives upside down. In a busy, fast-paced culture, where every minute of the day was accounted for in our busy agendas, this is a major change. Schools across the country have closed their doors and adopted ‘distance’ learning and some predict that they will not reopen their doors for students to physically return to school for the remainder of the school year, which is scheduled to come to an end during the month of May, 2020.

There are major travel disruptions to both international and domestic travel with restrictions for foreigner nationals who have visited certain countries, as well as port of entry restrictions.

 

Boston

Dr Soni Mathew, Consulting Physician

9 April 2020

Current lockdown status: On 2 March the Massachusetts Department of Public Health announced its first presumptive positive case of COVID-19 since testing started Friday, February 28, at the State Public Health Laboratory. Governor Baker issued an emergency order for closure of all Massachusetts public and private schools from 17 March until 4 May.

 

Impact on the community: The Boston Marathon was rescheduled from 20 April 20 to 14 Sept.
 
On 20 March a man in his 80’s was the first person to have died from COVID-19 related illness in Massachusetts.
 
Businesses and organisations not on the list of essential services were encouraged to continue operations through remote means that do not require workers, customers, or the public to enter or appear at the brick-and-mortar premises closed by the order. Restaurants, bars, and other establishments that sell food and beverage products to the public are encouraged to continue to offer food for take-out and by delivery, if they follow the social distancing protocols outlined in the Department of Public Health guidance. On-premises consumption of food or drink is prohibited.

All travellers arriving in Massachusetts are instructed to self-quarantine for 14 days. Visitors are instructed not to travel to Massachusetts if they are displaying symptoms. Health care workers, public health workers, public safety workers, transportation workers and designated essential workers are exempt from this requirement.

 

A statue of a lone local hero in an urban Boston community.

 

Healthcare in Massachusetts: All assisted living residences are to ban visitors to protect the health of residents and staff. This is in addition to the federal guidance issued that bans visitors to nursing homes and rest homes.
 
All hospitals operated or licensed by the Department of Public Health or the Department of Mental Health are to screen all visitors and restrict visitation if individuals show any indication of illness.

The COVID-19 Response Command Center has been working with its Advisory Board of medical experts and epidemiologists from Harvard University, University of Guelph and Northeastern to refine models related to the expected surge of COVID-19 cases. These efforts include modelling the surge’s timing, number of cases, necessary bed capacity, and work to find facilities that will meet overfill capacity.

 

Response Efforts: In response, the aim is to find or build an additional 750-1,000 beds in field medical hospitals and other alternate care sites to reduce the strain on hospitals as much as possible.
 
Additional possible sites are identified for Field Medical Stations including the Boston Convention & Exhibition Center, Joint Base Cape Cod, Springfield’s Mass Mutual Building and other smaller locations.

The Command Center is also securing 1,000 beds in capacity for step-down care options in nursing facilities for stabilized COVID-19 positive patients who can be transferred out of the hospital to make room for those with a higher medical need.

 

Iowa

Dr Peter Matos, CMA Physician Advisor 

9 April 2020

Current lockdown status: In the state of Iowa, as of 4 April, Governor Kim Reynolds has chosen to not follow the lead of other states in issuing a shelter-in-place order.
 
The first case of COVID-19 landed in Iowa City in early March and has grown to a current total of 786 confirmed cases and 15 deaths in the state of Iowa.
 
Iowa is one of only five states within the US that did not mandate a shelter-in-place order as of 4 April. In comparison, residents within the state of Iowa are still able to gather in groups of ten, access some public parks as well as walk into some restaurants for take-away.
 
Within the state of Illinois, a neighbouring state, gatherings of any size are forbidden, all parks and playgrounds are closed and residents are not allowed inside any food establishment, except for supermarkets.

 

Impact on the community: Pressures have been mounting for states to take more drastic efforts in fighting the spread. However, Iowa Governor Kim Reynolds, argues the current response has been keeping residents safe. The Iowa Board of Medicine unanimously recommended on 3 April that the state immediately issue a shelter-in-place order.

 
Supermarkets and businesses have taken it upon themselves to assist patrons in practicing social distancing and good hand hygiene. Some have been quicker to adhere to social distancing guidelines than others, leaving residents at risk. An Iowa supermarket chain has recently taken stricter action to help shoppers maintain adequate social distancing. In Davenport, Iowa, the store made sanitizing wipes available to shoppers were still expected to wipe down their own cart but were guided through the store by blue arrows and markers on the ground with the reminder to stay six feet away from other shoppers.

 

 

Los Angeles

Dr Myles Druckman, Vice President - Medical Services

9 April 2020

Current lockdown status: Lockdown began on 20 March. Los Angeles County rates per capita are still about 10% of the rates seen in New York City. 

 

Impact on the community & local perspectives: A shelter-in-place order remains, with authorities arresting those who violate the order.

In Los Angeles no one walks, everyone drives and the traffic is very bad. These are common refrains expressed by visitors. Compared to New York City, this is true, and it may be a reason why Los Angeles has not seen the rapid rise in cases.  In our car, as opposed to public transit, we limit exposure.  Also, Los Angeles is less population dense than New York – with fewer apartments and more residential detached homes, which also limits exposure. Finally, if warm weather and UV light are positive factors, we have that too. Los Angeles County is the largest county in the USA with over ten million residents. Within the county are many communities like Santa Monica, Sherman Oaks and Pacific Palisades. The Public Health authorities have been very responsive to COVID-19 and communicate at least daily with updates. They provide case data right down to the community level. Most people are carefully following the authority guidance and staying home, though the odd surfer may continue to get caught waiting for a different kind of wave.

 

A surfer who was caught be the coast guard.

 

Texas

Dr Chris Amos, Director - Institute for Clinical and Translational Research

9 April 2020

Current lockdown status: A stay at home order was declared by the Governor on 2 April and it currently expires on 30 April. Educational facilities were closed around 19 March. Nonessential services and activities are cancelled. Across the state, cell phone data has been used to track distances travelled in Texas and shows about a 35% decrease in travel. 

In Houston, all the counties in the region issued stay at home orders around 25 March. Major events including the Houston Livestock and Rodeo Show starting on 3 March was cancelled after a law enforcement officer attending a pre-event barbecue tested positive for COVID-19. Average travel in Harris county has shown decreases in the 30-45% range with current decrease being 35%. 

The timing of the peak of pandemic cases and hospital requirements is predicted to occur on 9 May. 

The overall period of peak infection and hospital use is projected to occur in mid-April and will exceed hospital capacities in several regions.

 

Impact on the community: Statewide projections suggest that the peak demand for ICU beds and ventilators can be met, but local regions such as Harris County and Dallas County could exceed capacity. Figure 1 shows the projected demands on hospital services in the state of Texas.

 

Clinical Studies: The Texas Medical Center is a leading academic environment that houses 54 medicine-related institutions, with 21 hospitals, four medical schools, seven nursing schools, three public health organisations, two pharmacy schools and a dental school. All of these institutions have closed all nonessential services and all lab-based non-COVID-19 research to reduce the likelihood of COVID-19 infection among faculty and to reduce the demand on PPE that would otherwise be required for managing animal facilities and core laboratories. At the Baylor College of Medicine there are 22 approved and seven pending protocols devoted to studying novel treatments for COVID-19, prevalence of infection in hospital workers, high risk populations and in communities, and social effects of COVID-19 on families and communities. 

 

What is International SOS doing on the ground? At the Baylor College of Medicine, we have been very involved in evaluating the impact of the COVID-19 infection on Harris County demand for hospital services and in studying characteristics of outbreaks in more defined environments. A forward time simulation of the effects of different approaches to managing small populations who either quarantine before or during a period of isolation was developed and applied to for a client interested in understanding the dynamics of an outbreak if it occurred during transit on a shipping rig. These software applications can be applied for various sized populations.

 

 

BRAZIL

Dr Ivan Drummond, Medical Director

9 April 2020

Current lockdown status: In Brazil, major city shops are closed; only supermarket and supply stores remain open; they all deliver and are functioning very well.

The number of cases is increasing. 

 

Impact on the community: Many COVID-19 hospitals are being mobilised. The plan is to increase capacity of ICU to more than 1,000 beds. Many doctors are testing positive for COVID-19 and this is now a major concern. At this stage, no doctors have died, however the exposure of health professionals is must be controlled. Hospitals are following PPR CDC protocols.

The general population, and society understand the risks. They are generally following proper health recommendations. There is a mix of fear and some hope.

 

CANADA

Ottawa

Dr Tarek Sardana, Consulting Physician

9 April 2020

Current lockdown status: Ottawa is Canada's National Capital and it has a population of just over one million. It is a similar city to Washington DC in that Ottawa is home to the Government of Canada. COVID-19 has been taken seriously in Ottawa. On 25 March the Mayor of Ottawa, Jim Watson, declared a "State of Emergency" for the Ottawa area; this coincided with the Province of Ontario's decision to declare an emergency.
 
All non-essential services were shut down and all level of government officials (municipal, provincial and federal) are working from home unless declared in an essential position. All public education facilities have been closed for about a month with schools likely remaining shut for the remainder of the school year. A massive campaign is underway to have residents follow social distancing protocols

 

Impact on the community: It currently appears that the "flattening of the curve" activities have been successful in that local healthcare facilities have been able to keep up with current demands. In preparation for increased demands, many temporary hospital type facilities have been constructed in anticipation of the oncoming wave. Ventilators and masks are in high demand as they are globally.

 

 

COLUMBIA

Dr Alvaro Saclemente, Medical Director

9 April 2020

Current lockdown status: Colombia has closed all land, air and sea borders until 30 May. All international flights have been stopped for 30 days. A national quarantine has been declared. All Colombians must shelter in place and remain inside until 30 April. For those over 70, the quarantine lasts until later in May and most public locations are closed. Only one member of the household may leave to purchase groceries or medicine. Schools are closed, hospitals are coping relatively well in the main cities but smaller cities and towns struggle. Unemployment is rising, and medium and small businesses are struggling to survive. Larger businesses are furloughing their employees or closing down operations. Banks and financial institutions have provided special conditions, freezing loan payments and interest charges for a couple of months, however these measures aren’t deemed sustainable.

Industry and commercial associations are pressuring the government to release or at least soften the quarantine measures, to avoid a total collapse of the economy. There’s an announcement by the President expected this week.

Impact on the community: Colombians are enthusiastic and happy, but the quarantine has affected the mood. People are used to gather for special celebrations including Easter religious activities and the current situation has prohibited them from enjoying as usual. People will not be able to make their trips to the beach or leisure farms.