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Zona TES Octubre-Diciembre 2017

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SPECIAL ARTICLE

Nine months after the WHO declaration: The New York City COVID-19 experience

George W. Contreras, DrPH(c), MEP, MPH, MS, CEM, EMTP

 

Assistant Director of the Center for Disaster Medicine and Assistant Professor, Institute of Public Health, at New York Medical College. He is an Adjunct Associate Professor at John Jay College of Criminal Justice and Adjunct Professor at Metropolitan College of New York. Paramedic in New York City Emergency Medical Service (NYC EMS).

 

 

Key Points

  • Although New York City (and surrounding areas) has overcome the initial wave of COVID-19 and was the epicenter of the pandemic in the United States, it is now (in August) demonstrating a constant decrease in terms of new cases and hospitalizations.
  • The majority of the United States is now (in August) experiencing an increase in new cases and hospitalizations as part of the initial wave of COVID-19.
  • Until safe and efficient treatments or vaccines are available to the public, the best strategy to follow is: stay home if possible, wear face coverings, maintain physical distance and frequent hand hygiene.
  • If you stay home, there is no exposure; if there is no exposure, there is no risk of infection; if there is no infection, there is no risk of illness; if there is no illness, there if no risk of death.
  • Public health needs to guide the economic stability of regions.
  • Public health and economics need to collaborate not compete with each other.

 

 

Background

SARS- CoV 2 was officially reported to the World Health organization (WHO) on December 31, 2019. The disease caused by this novel coronavirus thus became known as COVID-19 because it was named in 2019. The first case was reported in United States on January 22. The WHO declared COVID-19 a pandemic on March 11th. As we have just passed the six-month period, we have reached unbelievable milestones. This novel coronavirus started in Wuhan and is now found in 188 countries around the world as part of the current pandemic. Large outbreaks occurred in China, then Europe and the United States with New York State and New York City being the epicenter of the initial wave in the United States. Table 1 provides reported positive cases, deaths, crude case fatality rates (which are calculated by dividing deaths by reported cases) and populations of select countries. I use the word “crude” to highlight that the case fatality rate may actually be lower if there were widespread testing of the entire population. Although it is clearly concerning to see the number of cases increase in various countries, one also has to put perspective of the number of cases based on the population of that specific country or region.

 

 

TABLE 1.  Select countries with reported populations, cases, deaths and crude case fatality rates1 (August 31st, 2020).

Tabla 1. Comparativa de países: poblaciones, casos declarados, muertes y tasas brutas de mortalidad notificadas a 31/08/20202

 

 

July 4th is a major holiday in the United States because it represents Independence Day. In 2020, this holiday represents a “new normal” in the middle of a historic pandemic. New York Governor Cuomo implemented Stay-at-Home orders on March 23th. Since that time, New York became the epicenter of the initial wave in the United States and is currently at the end of the initial wave. On May 15, different regions started to slowly reopen using a four-phase approach based on the Centers for Disease Control and Prevention (CDC) guidelines2 which are:

  • Decrease of overall hospitalizations for 14 consecutive days.
  • Decrease in the number of deaths.
  • New hospitalizations must be less than 2 per 100,000 persons.
  • General hospital bed capacity must be at least 30%.
  • Intensive care unit (ICU) bed capacity must be at least 30%.
  • Testing capacity must be at least 30 per 1,000 persons per month.
  • Contact tracers must be at least 30 per 100,000 persons.

New York City (NYC) entered Phase 1 on June 8th which allowed construction and manufacturing businesses to open and approximately 500,000 went back to work. On June 22th, NYC entered Phase 2 and an additional 500,000 returned to work as outdoor dining, hair salons and barber shops reopened. On July 6th, Phase 3 allowed for additional reopening to include spas and tattoo businesses but not indoor dining (as originally planned) which highlighted the ongoing concern for continued spread throughout the community. New York City will enter Phase 4 on July 20 but with various restrictions such as no indoor activities at cultural institutions or malls. New York City is the last region in New York State to enter Phase 4 with the restrictions due to the high number of cases throughout the rest of the United States. As of August 31, New York City still has no indoor dining and has no plans to reopen in the near future.

 

For the past few weeks, there have been protests all over the nation including in New York City. There were riots and civil unrest in the Big Apple. The pandemic was overlooked or forgotten as thousands of people gathering in the streets to speak out against the systemic racism that has persisted for such a long time. During these protests, there were thousands of persons gathered in public locations throughout the country. There were also many confrontations with police and even episodes of looting.


The COVID-19 impact in the United States has multiple layers including:

Economic

Almost 50 million persons in the United States are currently unemployed as a result of the stay at home orders implemented across the nation. In May, people just started to return to work as cities reopened across the country. The rush to reopen, however, is now under closer review as many of the cities which reopened in the past few months are experiencing increases of new cases.

Healthcare

In the United States, the healthcare systems and hospitals were simply overwhelmed. We are currently seeing this frustration across the many states in the nation. The healthcare workforce was overwhelmed. In New York City, hospital personnel were not prepared to see so many critical patients in such a short period of time. They were not ready to see so many patients die in that same time period. Hospital morgues were overfilled in a short period of time. Refrigerated trucks had to be dispatched to every single hospital in order to serve as additional morgue space. Each truck could hold up to fifty deceased persons. Many hospitals had four, five, six trucks parked outside their hospital for months. These images served as a constant reminder to the communities of what was happening (figs. 1 and 2).

 

 

Figura 1.  Camiones refrigerados instalados en el exterior de un hospital de la ciudad de Nueva York que funcionaban como morgues adicionales en los peores momentos de la pandemia.

FIGURE 1.  Refrigerated trucks installed outside a New York City hospital that served as additional morgues at the height of the pandemic.

 

 

Figura 2.  Interior de un camión refrigerado acondicionado como morgue para dar apoyo a un hospital en Nueva York.

FIGURE 2.  Interior of a refrigerated truck conditioned as a morgue to support a hospital in New York.

 

 

Another major area of concern was the shortage of ventilators and intensive care units (ICU) at many of the hospitals in New York City. There was an initial shortage of critical equipment such as ventilators and adequate clinical space throughout New York City. Convention centers were retrofitted to become emergency hospitals. The USNS Comfort, a military hospital ship, was deployed to New York City. During the peak of the pandemic, there was thousands of additional hospital beds created to take care of the large number of patients sickened by the COVID-19. There was even a need to set up hospitals in the middle of Central Park (fig. 3).

 

 

FIGURA 3.  Hospital de campaña en Central Park que dio apoyo al Hospital Mount Sinai durante la primera oleada de la pandemia por COVID-19 en NYC.

FIGURE 3.  Central Park field hospital that supported Mount Sinai Hospital during the first wave of the COVID-19 pandemic in NYC.

 

 

Public health

Early in the pandemic, the United States suffered greatly from mistakes. Diagnostic testing was not readily available and the limited tests that were available were found to be contaminated and so they had to be discarded. The United States lost valuable time in late February and March regarding testing. Now there are more diagnostic testing and antibody testing which is widely available. For example, in New York State, as of today, anyone who wants a test can get a free test.

 

The strategy of contact tracing is now being widely used. This public health technique of isolating cases and contacting possible exposed people will improve the surveillance of the coronavirus. In order for this program to work, however, there needs to be widespread testing for everyone.

 

There is currently a greater public health concern due to incomplete compliance with public health mitigation strategies such as wearing face coverings, keeping physical distance, and practicing good hand hygiene. In New York City, as well as other parts of the world, many people are becoming complacent with these public health recommendations for several reasons including quarantine fatigue, frustration and the need to work and socialize as human beings.

 

Although a few states such as New York, New Jersey and Connecticut have survived the initial wave and have record low cases and hospitalizations, there are currently over thirty other states that are experiencing daily increases in cases and hospitalizations. Good contact tracing is important to try to monitor the spread of the disease. There were a few outbreaks during the initial wave but through fast contact tracing, there were able to be quarantined and helped to minimize the spread.

Mental health

The pandemic has caused not only physical but also emotional and mental toll on the public but especially on the healthcare workers ranging from the emergency medical technicians (EMTs) and paramedics who took care of the sickest patients at home to the physicians, nurses, respiratory therapists and other hospital personnel who provided continued care at the hospitals and nursing homes. A large number of patients died in a very short period of time. Many of the deceased were also colleagues who got sick and died from COVID-19 consequences. The inability to provide a normal wake and service also affected many of the families who lost their loved ones during this pandemic. In New York City, we even saw the toll of this pandemic take the lives of EMTs, paramedics and even physicians due to suicide.

 

EMERGENCY MEDICAL SERVICES (EMS)

New York City has one of the largest and busiest EMS systems in the world.3 From 1970 to 1996, New York City EMS (NYC EMS) was run by the Health and Hospitals Corporation. From 1996 to the present, the Fire Department of New York (FDNY) oversees NYC EMS in collaboration with private hospitals throughout the city.

 

In 2018, there were 1.8 million medical calls in New York City which averages around 5,000 calls per day. During the peak of this pandemic, over 7,000 calls were reach on several days. Response times were longer than normal and at the peak of the initial wave in New York City, there was almost 25% of staff who were sick from coronavirus. During March 1- April 25 in 2020, the number of non-traumatic cardiac arrests was three times the same period in 2019.4 At the height of the pandemic, there were 335 cardiac arrests in one day in April.

 

It was so overwhelming that the mayor of New York City and the Chief of EMS made public service announcements asking the public to NOT call 911 unless it was a true medical emergency. The city was simply overwhelmed. It was so bad that NYC needed to request the National Ambulance Contract (NAC) which activated over 400 ambulances and 1,600 emergency medical technicians (EMTs) and paramedics from all over the nation to assist New York City in its darkest hour. It was surreal to see so many ambulances without of state plates driving through the city. They arrived in mid-March and they completed their mission by May 28 when they returned home (fig. 4).

 

 

FIGURA 4.  Ambulancia del Estado de Virginia prestando ayuda al SEM de Nueva York como parte del plan de apoyo federal durante la pandemia.

FIGURE 4.  Virginia State ambulance providing assistance to New York EMS as part of the federal support plan during the pandemic.

 

 

During the peak of the pandemic, difficult decisions were made and temporary protocols were implemented in order to try to deal with the dire circumstances. For example, there were specific cardiac arrest protocol and after twenty minutes of resuscitation, the paramedics declared the person dead. Family members were not allowed to accompany loved ones in the ambulance, hospitals were not generally allowing visitors (except for one parent to accompany a minor) and patients with minor symptoms were even advised to stay home instead of going to the overwhelmed hospitals.

 

ISSUE OF PERSONAL PROTECTIVE EQUIPMENT (PPE)

During this historic pandemic, there were also shortages of different type of personal protective equipment (PPE) for many of the healthcare workers. The various types of PPE included gloves, gowns, googles, booties, head caps, N95 respirators and surgical masks. The biggest issues were N95 respirators and surgical masks due to extreme shortages. The situation became so dire that some organizations required that healthcare workers reuse N95 respirators under revised shortage protocols. Since this pandemic focuses on the respiratory system among other, the issue of protection from infection was very important (fig. 5).

 

 

FIGURA 5.  Paramédico con la protección individual como parte de la «nueva normalidad».

FIGURE 5.  Paramedic with individual protection as part of the "new normal".

 

 

TREATMENTS AND VACCINES

As this is a novel virus, we are still learning nine months into this latest pandemic. Although there are several treatments and vaccines in various stages of clinical trials, there are no approved treatments nor vaccines at this time. An approved treatment may become available before the end of 2020 but what is certain is that there will be no approved vaccines before 2021. Therefore, people all over the world need to do their part to keep the spread of the virus under control so that our healthcare systems, hospitals and personnel are not unnecessarily overwhelmed. The other critical thing to remember is that there is some concern regarding the politics of fast-tracking vaccines prior to the national elections in the United States. By fast tracking vaccines which may not necessary be properly and totally safe, the public health of the millions of people may be placed at risk for the sake of politics.

 

REOPENING OF SCHOOLS AND UNIVERSITIES

There is growing concern as the new academic year starts in August and September. Reopening schools and universities are an important stage since it represents a large number of persons re-entering the general population. Educational institutions have three choices: 1) continue traditional in-person classes, 2) a combination (or hybrid) teaching or 3) total remote (online) teaching. At the university level, across the United States, many universities have started to reopen. Some universities have, unfortunately, had outbreaks during their first few weeks and have had to shut down or transition to remote learning. Examples include the University of North Carolina at Chapel Hill on August 17 and State University of New York at Oneata on August 30. At the primary and secondary level, the issue is even deeper since students who stay at home must have adult supervision who may need to stay home from work. For example, in New York City, there are 1,1 million students at the primary and secondary level. New York City is currently planning to open their doors on September 10th, but parents and teachers are trying to delay the opening because they do not feel safe returning to the classrooms so early. The other problem is that it is also very disruptive for the teachers, parents and students to start in person and then suddenly change to online learning.

 

LESSONS IDENTIFIED

I do not like to use the term “lessons learned” because many times, we simply do not learn any lessons and keep repeating the same mistakes. In this article, I provided a brief summary of COVID-19 and some lessons identified in New York City so that we can successfully move forward. As one example, PPE was in some cases in limited supplies which caused some healthcare workers to reuse N95 respirators throughout their shift while taking care of many patients in the same shift. We identified this issue and need to modify our approach now before the next wave arrives. We have also identified mental health as an area that is and will continue to affect our healthcare workers as this pandemic is occurring over months to come.

 

WHERE DO WE GO FROM HERE

New York State is currently one of the few places in the United States were new cases and hospitalizations are decreasing. We have the lowest number of hospitalizations, new cases and deaths since the initial wave hit us. But we are concerned due to the warm weather, increasing frustrations of stay at home for over two months, past protests and overall mass gatherings. All these factors individually or combined can lead to an increase in cases and subsequent hospitalizations in New York City and other places.

 

We need to keep our guard up and we need to spread the message of public health to all. Avoid mass gatherings, continue to stay at home if you can. If you need to go outside, wear a face covering, wash your hands with soap and water (or use alcohol-based sanitizer), and keep your physical distance. Persons with chronic medical conditions (such as diabetes, obesity, hypertension and asthma) and the elderly need to be even more vigilant due to more possible severe complications. The unpredictability of a COVID-19 infection on individuals needs to be taken seriously in order to get through this historic pandemic and prepare for the possible next wave in the coming months.

 

The curve was flattened by public health mitigation strategies. We are now at pre-COVID levels in New York City. EMS is back to normal levels and the city gets ready for a new version of summer. However, in the rest of the nation, there are many places which have been having an increase in daily cases over the past several weeks. Many states who have reopened are struggling to have the communities maintain physical distance and wearing masks at mass gatherings. These actions are raising concerns that there will be uncontrollable transmission throughout the United States. And with the recent major holiday weekend, we will see how we did by the end of July. The summer 2020 will be very different as the majority of the United States struggles to keep ahead of the coronavirus.

 

Let us also hope that people will actually get the vaccine and it will not become an issue of debate similar to the flu vaccine which is widely available but some still refuse to obtain. In the meantime, public health mitigation strategies such as frequent and good hand hygiene, wearing face coverings and maintaining physical distance will certainly make an impact on controlling the spread of this coronavirus. This article is based on my personal experience working the front line as a paramedic and my additional knowledge as a public health and disaster management professor throughout my nearly thirty-year career.

 

 


 

REFERENCES

  1. Centers for Disease Control and Prevention (CDC). May 2020. Accessed July 1, 2020. https://www.cdc.gov/coronavirus/2019-ncov/downloads/php/CDC-Activities-Initiatives-for-COVID-19-Response.pdf https://www.cdc.gov/coronavirus/2019-ncov/downloads/php/CDC-Activities-Initiatives-for-COVID-19-Response.pdf.
  2. Johns Hopkins University of Medicine. Coronavirus Resource Center. COVID-19 Dashboard. https://coronavirus.jhu.edu/map.html
  3. Contreras G.W. El Servicio de Emergencias Médicas de la ciudad de Nueva York: un servicio diferente con paramédicos al frente. Zona TES 2026(7):1;43-9.

 

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