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US Did Ohio get it right? Early intervention, preparation for pandemic may pay off.

02:00  10 april  2020
02:00  10 april  2020 Source:   washingtonpost.com

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Now, Ohio may be realizing the benefits of early intervention in the pandemic by its government and medical community. With about 5,100 covid-19 cases, it But an early look at Ohio ’s preparations and decision-making shows they reflect textbook recommendations for the way to handle an outbreak.

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On Feb. 26, two days before President Trump called the coronavirus outbreak the Democratic Party’s “new hoax,” the Cleveland Clinic alerted the public that it was prepared to quickly open 1,000 additional hospital beds should the need arise.

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Early implementation of certain interventions , including closure of schools, churches, and Because antiviral medications and effective vaccines may not be widely available at the beginning of a To investigate whether early implementation of individual interventions or of multiple measures reduces

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On March 4, the day Trump boasted that “we have a very small number” of infected people in the United States, Ohio’s Republican governor, Mike DeWine, shut down a weekend fitness expo expected to draw 60,000 people a day to a Columbus convention center. There were no identified coronavirus cases in the state at the time.

Now, Ohio may be realizing the benefits of early intervention in the pandemic by its government and medical community. With about 5,100 covid-19 cases, it has fewer than a third the number of people with the novel coronavirus in three comparably sized states — Michigan, Pennsylvania and Illinois. And Ohio has just a small fraction of the deaths reported in those states.

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The Cleveland Clinic, which eventually beefed up plans to expand from 3,200 beds to 8,000 should the worst occur, held just 150 covid-19 patients (along with 2,000 others) this week and is preparing to scale back some facilities. It is moving to lend medical personnel to cities such as Detroit and New York hit hard by the virus.

In the Cincinnati region, models now show that peak occupancy of hospital beds by covid-19 patients may be just 10 percent of the predicted worst-case scenario.

“You’ve got to make these decisions early. Early means early,” DeWine said in an interview this week. “Every day you wait, you create a bigger problem.”

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With the pandemic still spreading and case counts rising, it’s too early for certainty on whether Ohio’s actions have spared it the worst of the virus’s impact. Experts caution that infectious disease outbreaks never move smoothly through a population. They arise opportunistically: A party here or church service there can produce an explosion of infections that quickly puts public health officials behind the disease curve. There is no way to account for luck, good or bad. 

But an early look at Ohio’s preparations and decision-making shows they reflect textbook recommendations for the way to handle an outbreak. Identify it early. Plan for the worst, hope for the best. Move swiftly because disease expansion will be exponential, not linear. In the absence of testing, assume the virus is spreading through the community. Communicate with the public clearly, and keep the message consistent.

“It seems we have gotten ahead of it,” said Tomislav Mihaljevic, chief executive of the Cleveland Clinic, one of the top medical systems in the country. “Here in Ohio, we may well be in a position of not a high, high curve of patients but more of a swell.”

Through Thursday’s report, Ohio had 5,148 positive cases and 193 deaths from covid-19, according to the COVID Tracking Project, a small group of journalists and others amassing data from public sources. The state had performed more than 53,000 tests.

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In Pennsylvania, there were 16,239 cases and 309 deaths after nearly twice as many tests. Illinois has seen 15,478 cases and 462 deaths, after testing 75,000 people. Michigan, which has a smaller population than those three states, had 20,346 cases and 959 deaths after conducting the same number of tests as Ohio.

Even neighboring Indiana, which has a little more than half of Ohio’s population, has 5,943 confirmed cases and 203 deaths, despite performing only 31,000 tests.

Having been through infectious disease outbreaks such as SARS and the H1N1 flu, Ohio has a well-established emergency medical response system. The state is divided into three regions, each clustered around major population centers in Columbus, Cleveland and Cincinnati. Planners call these zones the “three C’s.”

Their CEOs met and agreed to drop their historical competition for shares of the market and collaborate on just about everything, said Richard P. Lofgren, president and CEO of the University of Cincinnati’s health system.

As news of the outbreak in China began to spread in early January, epidemiologists and infectious disease experts at the three major medical centers in those regions began to track the spread. Soon, they were modeling the potential impact in Ohio and meeting more regularly to prepare.

“The ‘uh-oh moment’ was looking at news reports coming out of Wuhan and China,” said Robert Wyllie, chief of medical operations at Cleveland Clinic, referring to the Chinese city where the outbreak began. By Jan. 20, the first U.S. patient, a man in Snohomish County, Wash., had emerged.

March 4 was the day that defined the crisis for the state, everyone involved agrees. Columbus was scheduled to host Arnold Schwarzenegger’s sports festival — known as “The Arnold” — a weightlifting competition and fitness expo that would have jammed 60,000 people together each day in the city’s convention center.

After consulting with health experts, DeWine ordered everything but the competitive weightlifting events canceled, a decision that cost the city tens of millions of dollars. Columbus Mayor Andrew Ginther (D) concurred.

Without a single coronavirus case identified, DeWine’s decision created controversy and backlash. Only California Gov. Gavin Newsom (D) and Washington state authorities had ordered similarly harsh restrictions at the time.

“Everyone on the phone understood the implications of the decision we were making for the local economy,” said Andrew Thomas, chief clinical officer for the Ohio State University Wexner Medical Center, who was part of the team that advised DeWine and is coordinating the Columbus region’s response. “It was a difficult decision to make. It was at the time putting us way out in front of where most communities were.”

In retrospect, the sports festival forced planners to confront the pandemic days, and in some cases more than a week, before other communities. DeWine would go on to close schools and businesses, and order residents to stay home, earlier than most other states. His March 12 school order was one of the first in the nation. Ohio State University, with 68,000 students on multiple campuses, went to online classes March 9 and extended it to the rest of the semester March 12.

“When it came down to it, we were in some ways lucky that we were asked the question early, and we answered it correctly,” Thomas said. DeWine credited state residents with taking the restrictions seriously and observing them.

While children have largely been spared serious illness in the pandemic for reasons that are unclear, some public health officials believe they are spreading the disease, especially to parents and grandparents — although that remains open to debate.

Jennifer Nuzzo, an epidemiologist at the Johns Hopkins Bloomberg School of Public Health’s Center for Health Security, said in an email she is “skeptical that school closures will do much in the end,” although other social distancing measures clearly are having an impact.

Ohio also may have benefited because even its largest cities are not as densely packed as Chicago, where the virus spread quickly, Nuzzo said.

As DeWine was shutting down the state, the three large medical systems were frantically scaling up. The Cleveland Clinic, using a model with more dire predictions than their counterparts in Columbus and Cincinnati, determined it would need to expand to 8,000 beds to handle its peak load of covid-19 patients.

The system made plans to install 1,000 beds in its new medical school. It took over a hotel where 150 beds could be added. It put two beds in rooms meant for one patient. It stopped sending back expired protective garb and began scouring the marketplace for more. It designated some of its hospitals “covid-19 only,” so people with the disease wouldn’t mix with patients admitted for other medical problems.

“We looked at every nook, every cranny, every closed floor,” Wyllie said.

In Cincinnati, where planners were working with a more conservative model, officials nevertheless realized they would need 1,839 ventilators on the worst day of the crisis — twice what they had, said Evaline Alessandrini, senior vice president and chief medical officer for UC Health, affiliated with the University of Cincinnati.

In Columbus, which estimated it would need 7,500 beds — 1,000 more than hospitals had — officials set to work installing them, along with staff and equipment, in the convention center where the Arnold fitness expo had been scheduled.

Then, social distancing appeared to help curb the virus. “We see here in Columbus that people living in our communities have really listened to the recommendations,” said Harold L. Paz, chief executive of the Wexner Medical Center at Ohio State.

Cincinnati’s peak is now forecast to be 291 cases — about 10 percent of the original prediction — on April 28, according to modeling Alessandrini received Tuesday. The number is so low she is hesitant to trust it yet. The peak is also later than originally predicted, and patients should arrive in a manageable order, not the crush that New York City experienced, she said.

That doesn’t mean Ohio is out of the woods. Experts expect flare-ups as the pandemic fades — a saw-toothed curve rather than a smooth downward slope.

“They’re going to come from the hot spots like prisons and nursing homes, where people can’t socially distance,” said Thomas, Ohio State’s chief clinical officer. Any one of those could produce an explosion of disease.

Persuading cooped-up residents to accept a very gradual return to something like their previous lives will require great discipline, officials said. For those reasons, Columbus and Cincinnati are not yet scaling back their facilities. Cleveland is also being cautious, though it is soliciting volunteers on its staff to work elsewhere.

“We probably need another week to see exactly where we’re heading,” said Mihaljevic, the Cleveland Clinic chief executive. “We still may get hit by a lot of people. We simply do not know. But these early signs are very encouraging. With every passing day of relative calm and quiet, there is increasing confidence that the peak of the wave is not going to be as high as predicted.”

leonard.bernstein@washpost.com

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