March 2020

The Nation Reviewed

Behind the coronavirus masks

By Nenad Macesic

An infectious diseases physician on facing COVID-19

The news of a new epidemic virus started with murmurings on Twitter. At first it was a curiosity, centred on an animal market in central China, soon followed by the familiar guessing game about which animal may have been the original host – bats were once again the probable culprit. As infectious diseases physicians, we began to debate what was known and what should be done. The frictionless transfer of people and goods made possible by globalisation has made any emerging epidemic just a plane journey away.

Before long, reports of patients admitted to hospital in China with a SARS-like illness emerged, followed by reports of deaths. What seemed to be a localised phenomenon suddenly loomed large, swollen with reports of new cases each day in China, then neighbouring countries and soon enough Australia. Hypothetical scenarios exchanged by the infectious diseases community over heated email chains suddenly became real, as the first, then second and third patients were diagnosed in Sydney and Melbourne. The disease’s name was changed from Wuhan coronavirus to 2019-novel coronavirus (2019-nCoV) to coronavirus disease 2019 (COVID-19).

In a hospital, a typical afternoon on the infectious diseases ward involves seeing patients affected by myriad illnesses either acquired in the community or resulting from other medical procedures (think surgery, chemotherapy, transplantation), and the occasional “zebra” (an unusual and rare diagnosis). One afternoon in early February, our regular unit meeting was cancelled in favour of an update on procedures around protective equipment. For the first time since the Ebola epidemic of 2014, we were dealing with the jargon of “donning”, “doffing” and “PPE” (personal protective equipment). We checked each other’s P2 respirators for the telltale rise and fall with inhalations and exhalations. Someone wryly noted that masks worn to ward off the poor air quality following the bushfires had found new purpose. They had become the symbols of this unsettling year. The duality of “mask” and “to mask”, signifying both hiding and protection, was not lost on me. The atmosphere in the room became calm, but it was tempered by the knowledge that our service could be called on at any time, night or day. Several dozen patients at our hospital were tested. Fortunately all were negative, making the virus seem more like the stuff of headlines than a live concern for our hospital.

Across town in another Melbourne hospital, COVID-19 was decidedly more real. Doctor Rupa Kanapathipillai had just spent the day caring for two patients with the virus. The child of Tamil doctors who migrated to Australia in the 1980s, Kanapathipillai became involved in global health through work with Médecins Sans Frontières (MSF) in Malawi before completing infectious diseases training in Melbourne. In 2014, shortly after she began working at the prestigious New England Journal of Medicine, the Ebola virus epidemic in West Africa started. Seeing the widespread carnage in some of the world’s poorest countries, Kanapathipillai felt compelled to act. She volunteered, and soon arrived at the very front line – working as a doctor in an Ebola treatment unit in Liberia at the height of the epidemic. Although she is now based in New York as an MSF infectious diseases adviser, Kanapathipillai typically spends a month over summer in Australia seeing patients in what is usually a sleepy period of the year. The arrival of COVID-19 during her Melbourne stint therefore came as a shock, heightened by the fact that she is now the mother of an eight-month-old baby. 

New trainees in infectious diseases started the same day as Kanapathipillai arrived on the ward, and they were plunged headfirst into their first epidemic. “Firstly, we have a duty of care to the patients,” Kanapathipillai resolutely told them, citing the patients’ fears, not just for themselves but also their families.

Was Kanapathipillai thinking about her bubbly eight-month-old? “With Ebola, it is a different level of concern,” she tells me. “We think of Ebola as having a high transmissibility and much higher case fatality rate. The heightened level of fear, the case fatality rate, the heat and physical discomfort of the PPE in the Ebola treatment unit made it feel almost overwhelming. Here, things are more controlled. We only have two patients, who are thankfully pretty well. I’m sure it feels very different in Wuhan.”

The protective equipment chosen for COVID-19 was modelled on experiences of the SARS epidemic, and the fact that the virus is similarly transmitted on droplets generated through coughing or sneezing. While the equipment is less restrictive than that for Ebola, breaches can and do happen. Kanapathipillai describes her meticulous routine in the hospital and at home: “I still avoid having any contact with my baby before I have changed all my clothes and showered.”

As a relatively new father myself, I can relate to the fear that our jobs could have enormous consequences for our families. Behind our masks, these are things neither of us want to think too much about.

There has been much debate about COVID-19’s case fatality rate (CFR), with a recent report separating patients into three bands. Those patients reported from China’s Hubei province (mostly with severe disease) had an estimated CFR of 18 per cent, and for cases detected in travellers outside mainland China (mostly with moderate–severe disease), a CFR of 1.2–5.6 per cent is reported. But if all cases are taken together, regardless of severity, the CFR drops to approximately 1 per cent. While both of Kanapathipillai’s afflicted patients were treated in single rooms, they remained in stable condition during their time in hospital. In fact, the most agonising decisions were over when to declare them cured, and when it was safe to discharge them from hospital. “There is just so little known at the moment, and each day brings new information…” she says, her voice trailing, reflecting the uncertainty. “They just don’t want to go out into the community and become Patient Zero of their own cluster, a cluster that would probably involve their families and friends.” In other recent epidemics such as Ebola and zika virus, there had been reports of patients remaining infectious many months after the initial event. While there have been no reports of such a long period for COVID-19, it is difficult to avoid letting past experience colour current perceptions.

Given the absence of proven treatments and the fact that a vaccine could be more than a year away, stopping the spread of the virus remains the priority. Yet there is still no consensus about the best way to do this. Had our government been too draconian in placing those repatriated from Wuhan in quarantine on a faraway island and stopping flights from China to Australia? Are hospitals the best place for assessing suspected cases of COVID-19, given the possibility of in-hospital transmission, including to medical workers? Although two patients have been treated in Kanapathipillai’s hospital, many more identified as being at-risk have been tested for the virus. The need for quarantine and rapid expansion of testing efforts create an incredible burden on hospital resources that may already be stretched.

The potential consequences if procedures fail are terrifying, as demonstrated when a man evacuated from China was mistakenly discharged from a San Diego hospital only to later test positive. In Australia, where hospitals work with state health departments and there is no single authority overseeing these efforts, coordinating the response to this threat is a difficult balancing act and has led to calls for the creation of a national body, akin to the Centers for Disease Control and Prevention in the United States.

Some aspects of the response to COVID-19 have been impressive both in their rapidity and as technical achievements. The whole genome of the virus was sequenced and shared globally by Chinese authorities on the weekend of January 11–12. There are already more than 100 relevant scientific papers that have been made publicly available prior to publication in journals. Clinical trials of new antiviral agents are under way. Yet despite efforts at pandemic preparedness and all of the technological advancements of our age, the cornerstone of our response lies in a practice dating back to the Middle Ages, or earlier, with all the attendant collateral damage that this brings. The word quarantine comes from quarantino, a Venetian variant on the Italian quaranta giorni, describing a policy in the 14th century, when ships arriving in Venice from infected ports were made to remain anchored for 40 days before landing. 

There are limits to the practice. Kanapathipillai points out that our hospitals may be able to quarantine dozens of patients with COVID-19, but what if that number reaches hundreds? At the time of writing, there are still many thousands of cases worldwide, and the infection and fatality rates vary daily. The peak outside China likely remains several weeks away. Even for hardened veterans like Kanapathipillai, the first 40 days have only raised further questions. Hopefully another 40 days will bring some certainty.

Nenad Macesic

Nenad Macesic is an infectious diseases physician and researcher based in Melbourne.

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